Integrated Package Policy Quick Quote Form for Continuum of Care Facilities

Premier Insurance Management Services, Inc. makes getting a quick quote easy! Simply enter your information in the fields below and click 'Submit'.

Insured Information
Insured Name:*
FEIN:*
Address:*
City:*    State:*   Zip:*  
Policy Information
Effective Date:
Current Insurance Carrier:
Premium:
Has there been more than 1 loss or claim in the last 5 years?*
Business Information
Nature of Business:*   
Number of Employees:*    Annual Payroll:* $
Annual Sales* $   
Address:*    County:*   
Building Information
Year Built:* Construction:*
Sq. Feet:* # of Stories:*
Burglar Alarm:*
 Fire Alarm:*
 Sprinklers:*
  
Valuation Replacement Cost ( please indicate zero for any values unknown )
Stock:* Furniture & Fixtures:*
Improvements & Betterments:* Building Limit (If Owned):*
Contact Information
Contact Name:*
Contact Phone:*  ext:
Contact Fax:
Contact E-mail:*
* denotes required field
    

Should you have questions about this form or if you want to talk to a Premier representative, please contact:
Kelly Norman
Premier Insurance Management Services, Inc.
T – 704.733.5376
F – 704.733.4894
kelly_norman@premierinc.com
Premier Insurance Management Services, Inc., a wholly owned subsidiary of Premier, Inc. does business as Premier IMS Insurance Services in California and Premier I.M.S. Insurance Agency in Oklahoma and New York