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"Offering Complete Insurance Services Since 1887"  
Vaillancourt & Woodward
15 Exchange St
PO Box 8
Berlin, NH 03570
 
(603) 752 - 2440
(800) 734 - 3166
 
Fax: (603) 752 - 2583
 
Hours of Operation
Monday - Friday
8:30 am - 4:30 pm
 
Licensed In:
NH, ME, VT
   
     
Business Insurance Quote Request
In an effort to better meet your needs and get the correct information to you, we would like you to take a few minutes and fill out the following questionnaire.
Company Information:
Company Name
Contact First Name
Contact Last Name
Company Address
Company Address 2
City
State
Zip Code
Phone Number
- - (xxx-xxx-xxxx)
Fax Number
- - (xxx-xxx-xxxx)
Email Address
Date of Birth* (dd.mm.yyyy)
Social Security Number
- - (xxx-xx-xxxx)
Preferred Contact Method Email Phone Mail
Preferred Contact Time : am pm
Current Insurance Company (not agency)
Policy Expiration Date - - (MM-DD-YYYY)
What types of coverages do you currently have?
(Please select all that apply.)
Bond Commercial Umbrella Group Life
Commercial Auto Disability Profess
ional Liability
Commercial Liability Group Health Workers' Compen
sation
Commercial Property Directors & Officers Liability    
Other
 
Number of Full-Time Employees
Number of Part-Time Employees
Amount of Time in Business
Number Of Locations
Annual Sales
Please give a brief description of your business and clientele: (Limit 250 Characters)
What type of coverage do you want?
(Please select all that apply.)
Bond Commercial Umbrella Group Life
Commercial Auto Disability Profess
ional Liability
Commercial Liability Group Health Workers' Compen
sation
Commercial Property Directors & Officers Liability    
Other
If you have any additional comments about the coverage you desire, please enter them in the box provided below.
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