EMB Specialty ~ Insuring your business & life ~ Request a Quote / Information


Phone/Fax - (610) 857-4759	[ request a quote ] [ contact us ] [ home ]

Please fill out all applicable sections. One of our agents will contact you within 24 hours after submitting your request during week day hours.

Name



Address			City	State	Zip
Home Phone	Business Phone	Cell Phone or Alternate Phone #		Fax
Email Address			Contact me at	Best Time to Call

If you have more information about the type of insurance that you are seeking, please provide it below.
Do you own your home or building:	Yes No
Are you requesting personal auto coverage?	Yes No
For Business Insurance Requests:
What type of business are you?
How many years have you been in business?
How many employees to you have?
Do you need Business Health/Disability/Dental/Life coverage?	Yes No
Do you need Business Auto coverage?	Yes No
List your Corporate Officers:
What is your annual payroll?
Have you had any claims in previous 5 years?	Yes No
If yes, please give details:

How may we help you with your business or personal insurance needs?


For Life - Health - Disability - Dental - Long Term Care Quotes:
What is your age?	Are you a smoker? Yes No
For joint coverage:
What is your spouses age?	Is your spouse a smoker? Yes No
General Comments - Let us know how we can help:

Thank you for allowing us the opportunity to explore insurance options for you. We look forward to working with you for all of your insurance needs. One of our professionals will be in touch with you very soon!