Disability Insurance

At NEC Insurance Agency, Inc. We put the power of the internet to work for you! The following questions concern the type of business insurance coverage you are requesting . Please answer them as accurately as possible.

1) Business Name:    

2) Description of the business:    

3) What type of entity is your company?    

4) Please indicate the state in which your business is located:

5) Please indicate your total # of full-time employees:

# of Part Time Employees:

6) Do you want the officers of the company to be included?  Yes No

7) Please indicate your total annual revenue:

8) Please indicate your total annual payroll: Please enter amount: $

9) Do you currently have business auto insurance?  Yes No

If you are currently insured, please select your current insurance carrier:

If your provider is not listed above, please provide the company name here:

10) How many years have you had coverage with this company?

11) How many years have you had continuous coverage (With no lapse)?

Business Information:

1) Business address:

Business address:

2) City:

3) State:

4) Zip Code:

The answer to these basic questions will help us process your information.

1) Best Time To Contact:    

2) Additional Comments:
Please provide any additional information you feel is pertinent to the insurance coverage you need.


1. First Name:     

2. Last Name:      

3. Phone:              

4. Email:               

5. Address:          

6. Address:          

7. City:                   

8. State:                

9. Zip Code: