~Goebel Business P.C. Sheet to Quote~ .pdf

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Original filename: ~Goebel Business P.C. Sheet to Quote~.pdf
Author: Federated Insurance

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Fond du Lac Branch:

Green Bay Branch:

Phone: 920-921-7526  10th Largest Mutual Insurance Company in the Country
Phone: 920-251-9004
Fax: 920-923-5976
Fax: 920-227-2247
Address: 45 S Main St  Federated Insurance is Rated A+ by AM Best and on the Ward’s
Address: 3599 Dickinson Rd
Top- 50
Home - Health
- 401k
Rollovers - Life
Disability - Risk Management - Commercial P/C - Work Comp - Group Benefits
du Lac,
WI 54935
De Pere, WI 54115

Goebel Insurance has access to over 20 commercial carriers for Property/Casualty and Work Comp
We provide enhanced risk management services, even beyond what the carriers provide
Ask about our Forklift Certification program, “Big Buck Contest”, and Employee Incentive Programs

Business Insurance Quote Information
To get a business quote, please fax these additional documents:

1. Employee Drivers List (if applicable)

Please include employee name, date of birth, and driver’s license #

2. Vehicle List (if applicable)

This can be taken right from the auto section in your policy
Include the Year, Make, Model
Please indicate which vehicles you want comp/collision on.

3. Work Comp Codes and Payrolls (if applicable)

This can be taken right from the work comp section in your policy or email the #’s

3. Loss History on Claims (Last Four Years)

If you don’t have this, we will send a signed sheet to your current/past carriers.

Legal Business Name: _________________________

Renewal Date: _____________

Please list all Owners and %: ___________________________________________________________

Included in Work Comp? ____ Gross Receipts last fiscal year: ___________ Federal ID #: __________

# of Employees: _____

Entity Type (Ex: S-Corp): __________
Current Insurance Carrier: ______________

What is your limit for the following:

Building: _________ Contents: _________ General Liability: _______ Auto: _______ Umbrella: _______
In the past three (3) years, how many claims have you had in the following:

Property: _____ General Liability: _____ Auto: _____ Work Comp: _____ Crime: _____ Other: _____

To get a tailored plan, please email/fax the info to Tony by ________________.

Tony Goebel, LUTCF, CITRMS
Exec VP - Insurance & Group Benefits Advisor
Email: tony@goebelins.com
Phone: 920-251-9004
Fax: 920-227-2247
If for some reason the fax # is not working, please
call me and I will pick up the information for you.

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