Phillips & Phillips - Online Ordering Request

Date:

Agent:

Insurance Co.:

Agent Phone:

Underwriter:

Underwriter Email :

 

Insured Information

Policy No.:

Contact:

(Last Name, First) Name:

Contact Phone:

D.B.A.:


Location Address

Phone:

Same as Mailing Address?

Business Type:

If No, then provide the location address and contact:

Mailing Address:

Location Address:

Mailing City:

Location City:

State:

Zip:

State:

Zip:

 

Assignment Selection

 

Inspection/Valuation

Premium Audit

 

 

 

 

 

 

Audit Period: To:

Code

Code Description

Exposure

Please indicate any officer exclusions or special exceptions below in
the Special Instructions or Comments section.
 

 

Building Coverage $:

 

Special Instructions or Comments

 


Note: If different than the underwriter's email address, then please provide your email address.

 

  

 

Please "Submit Request" after each request. A confirmation screen will appear indicating a successful transmission.

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