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:
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Spouse's Name:
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Children:
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Address:
 
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*Email:
 
  Business Information
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Address
 
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Business Phone:
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  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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