Phone: 305-592-7700
Fax: 305-593-8785

Main Office:
8726 NW 26 St. #11
Doral, FL 33172


Please complete the following form and you will be contacted by one of our Customer Service Representatives with a quote:

* Required Fields

Company Information

Name of Business:
DBA Name:
FEIN #:
Address:
City:
State:
Zip Code:
*Contact Name:
*Contact Phone:
*Contact Email:
Description of Business:
Number of Employees:
Years in Business:
Payroll Total:
Gross Annual Sales:
Prior Insurance:
Expiration Date:
Claims:

Property Information
Year Built:
Total Area:
Roof Type:
Construction Type:
Nomber of Floors:
Is the Property Owned or Leased?
Alarm System:
Sprinkler System:

Covergage Information
Building:
Contents:
Business Income:
Other Assets :
Theft Deductible:
Wind Deductible:
Coverage:

  

Percent:

  

Liability:
Products:
Per Injury:
Fire/Legal:
Medical Pay:
Deductible:
Value:

  


The information we collect will be stored securely and used only by Access Insurance Group to provide you with the best possible service. Access Insurance Group will not sell your information to any 3rd party. Submission of this form constitutes your consent to receive a call even if your number is on the National Do Not Call Registry.

 





 


 


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