Wufoo

Field Services Insurance by Leonard Insurance

Thank you for your interest in our field services insurance program. By completing and submitting the form below, we will provide with a no obligation quote for errors and omissions and general liability insurance that is accepted by ALL MAJOR REFERRING COMPANIES. This program was made specifically for your industry with one of the largest insurance companies in the world behind you (Chubb). Same day coverage and credit card payments are available. If you have questions, please call Terri Guiser or Darren Faye at 800-451-1904. We look forward to working with you!

Business Name *
Contact Name *
Type of Business
Limited Liability Company (LLC) Corporation Sole Proprietor Partnership
Federal Employer ID # (FEIN)
Address *
City *
State *
Zip Code *
Phone * ### - ### - ####
Fax ### - ### - ####
Email *
Year Established *
Gross (Estimated) Annual Revenue (cannot be zero) *
Do you use independent contractors?
Do you use a written contract?
Do you currently have general liability in-force?
Have any claims been made against you in the past five (5) years?
If there have been claims, please list dates, amount of claim, description and if the claim is still open.
Are you aware of any facts or circumstances or any incident which may result in a claim made against you?
Limit of liability desired:
Deductible desired:
Do you currently have a combined errors and omissions/general liability policy in force?
Current Carrier:
Current Limit:
Current Premium:
Current Retroactive Date:
Check the companies you work for, if applicable:
Fidelity National Five Brothers Safeguard Properties National Field Reps Field Asset Services First American Field Services M&M Mortgage Cyprexx Countrywide/Bank of America
Other companies not listed that you work for:
Do Not Fill This Out