AKCI New Business-Taggart Insurance

Business Name: *

Effective Date: *

Named insured: *

Contact Person: *

Phone:

Fax:

E-Mail:

Website:

Business Address: *

Mailing Address: *

Business Description:

Industry Type: *

Date Company was Established: *

# Employees:

FEIN: *

Any policy/coverage declined, cancelled or non-renewed in the last three years: *

Current carrier information, include policy number and effective dates for all policies: *

Any losses in the last 3 years: *

PLEASE CHECK DESIRED COVERAGE: *

Computer Limit:

Is this property over 20 years old:

Please check other coverage you may wish to consider:

This is not an all inclusive list. Taggart Insurance will be happy to provide a proposal for any coverage listed above. Additional information or applications may be required.

I accept the Terms and Conditions

Customer Services

Personal Insurance Suckerfish

Business Insurance Suckerfish

Employee Benefits

Very Well Health

Work Comp Navigator

Specialty Programs

Vehicle 1

Vehicle 2

Personal Information