J.M.F. Risk Management -- Request for Information

J.M.F. Risk Management - Complete Insurance Services since 1986

Please send us the following information, and we will get started right away to review market availability and pricing suited to your needs.

First Name:			Last Name:		Sex:
Street Address:
City:		State:		Zip:
E-mail Address:
Home Phone:	()
Evening Phone:	()
Best time to call:

Please list coverage limits desired in detail, or for an exact comparison fax a copy of your current policy to (914) 944-3497.

Type of Insurance	Present Insurer
Auto		Liability Limits/Property Damage: $
		Comp/Coll Deductibles: $
		Rental/Towing Limits: $
		Full glass: Yes No
		List any tickets/accidents in the last 39 months:

Home		Building Limit: $
		Personal Property Limit: $
		Year Built:
		List any losses within the past 3 years:

Life		Expiration Date of Current Policy:

Commercial		Building Limit: $
		Business Property Limit: $
		General Liability Limits: $
		Deductible Desired: $
		List any losses within the past 3 years:

Comments:

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Despite the security measures taken by J.M.F. Risk Management, Inc, there is an inherent risk in disclosing personal information over the internet.
Anyone electronically transmitting personal information assumes the risk that such information may be disclosed or intercepted by unintended third parties and J.M.F. Risk Management disclaims all liability resulting form such interception or disclosure. Anyone who wishes to apply for an insurance quote who is concerned about maintaining the security of their personal information may fax or mail the information to us at the address/fax above.