Applicant Information - Humphrey, Covill & Coleman Insurance Agency, Inc.

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Applicant Information

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Fields marked with an asterisk (*) are required.

Legal or Business Name *

Policyholder Name

Type of Operation *

Corporation

Individual / Sole Proprietor

Partnership / Joint Venture

Limited Liability Company (LLC)

Other

* Are you operating under a Doing Business As (DBA) name?

Yes No

DBA Name *

Other Type *

Contact *

Contact Email *

Confirm Email *

Phone *

This contact information will be used by insurance company personnel should there be a claim. It is the responsibility of the policyholder/insurance contact to retain all documentation, video or other evidence and respond immediately to all requests or inquiries from insurance company personnel.

* Is the above contact the insurance claim contact?

Yes No

Please enter the contact information for the person who would assist in the event of a claim.

Insurance Contact *

Ins. Contact Email *

Confirm Email *

Phone *

Mailing Address *

For Questions: Humphrey, Covill & Coleman Insurance Agency, Inc.
(508) 997-3321
pete@hccinsuranceagency.com