Quote Request

Thank you for requesting a quote from AFCO CAFO. Please provide complete information so we may respond promptly.

We ask that you use this Quote Request form only if you have a current business relationship with AFCO CAFO. Otherwise, contact us or submit an Agency/Brokerage Enrollment Form to establish a relationship. Thank you.


AGENT INFORMATION
Date: 03/10/10
Agent:
Contact:
E-mail:
Voice:
Fax:

INSURED INFORMATION
Insured:
Address:
City:
State/Province:
Zip/Postal:
Tel #:


Is Insured a renewal for AFCO CAFO? Yes No
If yes, Account Number:
Is Insured a renewal for agency / brokerage? Yes No
Is Insured in receivership / bankruptcy? Yes No
Are there any deposit premiums or retrospectively rated policies? Yes No
Are the policies auditable? Yes No
If Yes, are they auditable on other than an annual basis? Yes No
Do any policies require more than 15 days cancellation notice by any party? Yes No
If Yes, which ones?

If D&O coverage:
Can change of control cause policy to go into run-off?		 Yes No
In run-off, a) is policy fully earned?
b) can policy be canceled?
  Yes   No
  Yes   No
Is bankruptcy considered a change of control? Yes No


INSURANCE COMPANY/POLICY INFORMATION
Please provide contact names and phone numbers
Policy Effective Date  ( MM/DD/YYYY ) :  

Insurance Company Information
Company:
MGA/GA:
City:
State/Province:
Contact:
Phone:
  Policy Information
Coverage:
Days to Cancel:
% Min Earned:
Policy Term:
Premium Base:
Tax:
Fees:
Policy Number:
ENTER  ANOTHER  POLICY


Comments:

Plan Options:
20% and 9 payments
15% and 8 payments
10 Equal
other: 		Requested check release date:

Include:
Cash Flow:
Amortization:

Needed By:
Tomorrow
This AM
This PM
Immediately


SELECT THE AFCO CAFO OFFICE YOU WOULD LIKE THIS INFORMATION DIRECTED TO

Boston
Chicago
Edmonton
Dallas 		Kansas City
Miami (includes VI risk)
Montreal
New York 		San Diego
Seattle
Toronto