NON-PROFIT QUESTIONNAIRE

Applicant Name:

DBA:
Address:
City / State / ZIP:
Telephone/FAX:
Email/Website:
Location Address:
City / State / ZIP:


     Type of Organization:         
 

Please Explain Scope of Business:


Claims History (over the last 5 years)
Number of Claims Approximate Amount Paid Claim Details

To Submit Request:
-- Complete Form, Print then
 FAX to (415) 454-8311
 or



Please Note: Our Agency Will Contact You Within the Next Business Day After Submitting REQUEST


Full-Service Insurance Agency
817 Mission Avenue - San Rafael - California 94901
Tele. (415) 454-0100 - FAX (415) 454-8311 - Toll Free (888) 822-4INS(4467)
WWW.MichaelMillerInsurance.com
California Insurance License 0541868