Contact Request Form

If you work for or own a company that is looking for insurance please have your insurance agent/broker contact NECC. If you do not have an insurance agent/broker that you wish to work with then you can complete the following form. NECC will forward this information to an insurance agent/broker in your state. This is not an application for insurance.

Read this before you contact us.

For our mailing address and telephone numbers click here.

Coverage(s) Needed (Check all that apply):

	General Liability
	Professional Liability
	Contractors Pollution Liability
	Motor Vehicle Pollution Liability
	Site Specific Pollution Liability
	Umbrella / Excess Liability

Type of Business:

Limits Needed:

	$500,000 / $500,000
	$1,000,000 / $1,000,000
	$1,000,000 / $2,000,000
	$2,000,000 / $2,000,000
	$5,000,000 / $5,000,000
	Other:

Current Insurance:

	Carrier:
	Limit:
	Deductible:
	Retroactive Date GL:	Professional: Pollution:
	Expiration Date:
	Expiring Premium / Rate:


I Need a Quote By:


Your Name:
Company Name:
Address 1:
Address 2:
City:
State:
Zip:
Phone:
Fax:
E-mail


	Please contact me as soon as possible regarding this matter.

You must read this before you contact us.


Please type - yes				I read and understand that I am qualified to submit my request.

Note: This is only a contact request form. This is NOT an application for insurance.

For any other comments use this contact form