RFCP

1. Company Information:

Company Name*

Contact Name:*

Street Address:*

Street Address (cont'd):

Telephone:

Fax:

E-mail:*

Number of Store Locations:*

States Located:*

Stores per State:*

2. Current Insurance Program Information: Package:

Carrier:*

Renewal Date:*

Estimated Annual Premium:*

Loss Experience:*

Good Average Poor

3. I would like to set up a conference call the week of

Please contact me to set up a follow-up meeting by:

Telephone Email

Please enter the code you see above:

Everett Newman, Jr. CIC
Managing Vice President
York Alternative Risk Solutions
[email protected]
714.620.1378