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CGA Associates Personal Inland Marine Quote
We would like to provide you with a free, no-obligation insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Submitting Information
Business Name:
Contact Name:
Street Address:
City:   State:   ZIP:
County:   Email:
Business Phone: Fax:

Personal Information Section
Applicant's Name:
Mailing Address:
Mailing City:   State:   ZIP:
Email:
Day Phone:   Night Phone:
Best Time To Call:   AM   PM

Applicant & Location Information
 
Age:
 Marital
Status:
M  S		  
Occupation:
 Spouse's
Occupation:
 Territory
Code:
 Protect
Class:
 Fire District/
Code #:
Location of Property
(if different from above):

Additional Location		 Dwelling
Type(s):
 Construction
Type(s):
 # Families
(in each):
Other:

Coverages
Please indicate additional property that is not listed in boxes 10-14
# Property Amount of Ins.
# Property Amount of Ins.
  1 Jewelry $ 8 Coins $
2 Furs $ 9 Golfer's Equipment $
3 Fine Arts $ 10 $
4 Cameras $ 11 $
5 Musical Instruments $ 12 $
6 Silverware $ 13 $
7 Stamps $ 14 $
Unattended Car Coverage (Stamps/Coins)
Broad Form Pair & Set Coverage
Non-Mobile Organ Coverage
Safe Credit (Identify Property, Safe Class, Etc)
   ACV Loss Settlement
Replacement Cost Loss Settlement
Breakage Coverage (*On Schedule)
Blanket Coverage
Additional Rating Information

Additional Comments:
Please give any additional comments about the coverage you desire:

 
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