Applicant Information - Francis L. Dean & Associates, LLC

Applicant Information

(Step 1 of 5)

Fields marked with an asterisk (*) are required.

Policyholder *

Note: This is the name that will appear on your Certificate of Insurance.

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 *

Phone *

Contact Email *

Confirm Email *

Claim Contact? *

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 *

Phone *

Ins. Contact Email *

Confirm Email *

Mailing Address *

For Questions: Francis L. Dean & Associates, LLC
(800) 745-2409
info@fdean.com