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Business Name *

Please enter the official name of your business.

Years in Business *

Please enter the number of years your business has been active.

Legal Entity *

Please enter the legal status of your business.

Partners/Owners *

Please enter the number of owners or partners in the business.

Full-Time Employees *

Please enter the number of regular full-time employees your business has.

Will this replace an existing business policy? *

Part-time Employees *

Please enter the number of regular employees your business has who work part-time.

Sub-Contractors *

Please enter the number of regular sub-contractors your business employees in any given year.

Is this a one-time event or seasonal business? *

Annual Revenue *

Please enter the estimated annual revenue of your business.

Please describe the specific nature of your business. *

Please describe what your business does and all the typical services and products you provide on a regular basis.

When would you like this policy to start? *

Please enter when you’d like this new insurance policy to go into effect.

What type(s) of business insurance are you interested in?

Property/Casualty Insurance *

General Liability Commercial Auto Commercial Property Cyber-Liability Professional Liability Directors and Officers Liability Business Owners Package (BOP) Workers Compensation Commercial Crime

Employee Benefits *

Group Health Insurance Group Life Insurance Group Disability Insurance 401K / Retirement Plans Supplemental Plans / AFLAC Key Man Life Insurance Key Man Disability Insurance Deferred Compensation

Contact Name *

First

Last

Please enter your first and last name

Contact Email *

Please enter the best email address we can use to send your insurance quote.

Phone Number *

Please enter any additional information we may need to provide you an accurate insurance quote. You can also use this space to ask questions.

Additional Comments? *

Please enter any additional information we may need to provide you an accurate insurance quote. You can also use this space to ask questions.

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Your private information is provided exclusively to our agency and will not be redistributed or sold to anyone else.

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The Kilgore Agency, LLC.
9340 Helena Road
Suite F #160
Birmingham, AL 35244
(205) 739-3549
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