Phone: 606-474-5128
Fax: 606-474-5001
Email: info@millerins.net
Hours: Mon-Fri 9-5pm, Sat: 9-12pm
210 South Carol Malone Blvd
Grayson, KY 41143

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Business Insurance

General Information
Business Name
Contact Name
Mailing Address
Street Address
City
State
Zip Code
Business Phone
Fax
Best Time to Call
Contact Email Address
Current Insurance Information
Company Name (not agency)
Policy Expiration Date
Premium Amount $
What type of coverages do you currently have?
Bond
Commercial Auto
Commercial Liability
Commercial Property
Commercial Umbrella
Directors & Officers Liability
Disability
Group Health
Group Life
Professional Liability
Worker's Compensation
Other
If Other, Please Specify
About Your Business
Number of Full-Time Employees
Number of Part-Time Employees
Years In Business
Number of Locations
Annual Sales $
Please give a brief description of your business and clientel:
About Your Location
Building Construction
Roof Material
Servicing Fire Department
Miles to Fire Department
Feet to Fire Hydrant
Coverage Information
Please select the type of coverages you want:
Bond
Commercial Auto
Commercial Liability
Commercial Property
Commercial Umbrella
Directors & Officers Liability
Disability
Group Health
Group Life
Professional Liability
Worker's Compensation
Other
If Other, Please Specify
Additional Information
Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here:
Permission to Obtain Consumer Reports
To provide an accurate quote, we have asked you a series of questions some of which we will confirm through consumer reports, which may include credit, motor vehicle and loss information reports. This information will be available to our companies with whom we will obtain your quote.
Is it O.K. to continue
Yes No
Fraud Statement
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.
I have read the above Fraud Statement
Yes No

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