JamesEMoore

Pledge of Performance

Please fill out our contact form below to help our agents prepare relevant information before contacting you.

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*Are you currently a client with the James E. Moore Insurance Agency?

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*Has anyone referred you to our agency?

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If yes, who referred you?

Personal Information

*First Name:

*Last Name:

Date of Birth:

mm/dd/yyyy

Spouse's Name:

Date of Birth:

mm/dd/yyyy

Children:

Date(s) of Birth:
mm/dd/yyyy

Address:

City:

State:

(2 letter abbrev.)

Zip Code:

Home Phone:

Mobile:

Fax:

*Email:

Business Information

Business Name:

Type of Business:

Year Started:

Ownership Type:

Address

City:

State:

Zip Code:

Business Phone:

Mobile:

Fax:

Insurance Needs

Commercial:

check all that apply

	Automobile
	Boilers and Machinery
	Bonds
	Builders Risk
	Directors and Officers Errors and Omissions Coverage
	Employment Practices
	Excess and Umbrella Liability
	Flood
	Garage and Dealers
	General Liability
	Ocean and Inland Marine
	Professional Liability
	Property
	Trucker's Liability
	Worker's Compensation

Personal:

check all that apply

	Automobile
	Boats/Water Craft/Yachts
	Condominium
	Contents Coverage (For Renters)
	Dwelling Fire
	Flood/Excess Flood
	Health
	Homeowner
	Life
	Motorcycles
	Personal Property
	Personal Umbrella Liability
	Scheduled Personal Property (Jewelry, Collectibles, Antiques)
	Travel Trailers
	Wind and Hail

Life:

check all that apply

	Individual Term Life Insurance
	Individual Universal Life Insurance
	Individual Whole Life Insurance
	Individual Variable Life Insurance
	Annuities

Health:

check all that apply

	Individual Health Insurance
	Individual Disability Insurance
	Medicare Supplements
	Long Term Care Insurance

Employee Benefits:

check all that apply

	Group Health Insurance
	Group Life Insurance
	Group Short Term and Long Term Disability Insurance
	Group Dental Insurance
	Group Vision Insurance
	Cafeteria Plan (Section 125 Plan)
	Group Long Term Care Insurance
	Health and Dependent Care Reimbursement Accounts
	Health Savings Accounts (HSA)

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