Concord General Insurance Agency 310-551-1235

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General Information

Insured's Name
Phone Number
Fax Number
Email Address
Insured is:
Business Name
Street Address

City

Zip Code

Number of Owners	to be Included?
Number of Directors	to be Included?
No. of Employees

Annual Payroll
Annual Receipts

Type of business:

Nature of Business:

Loss History

Prior carrier and loss history for the past three years

From Mo. Yr. To Mo. Yr.

Company name

Policy number

Claims and losses: Number

Amount

Cancelled or Non-renewed

Reason

How did you hear about us

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TELEPHONE (310) 551-1235 & (310) 551-1236 Fax (310) 551-1250
400 South Beverly Drive, Suite 318, Beverly Hills, Ca 90212. USA.
E-MAIL sales@concordgeneralinsurance.com