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Insurance Center of Monroe - Insuring Michigan Residents & Businesses for Decades!
 
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Personal Auto Insurance

Homeowners Insurance

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Boat & Yacht Insurance

Business, workers comp, and Contractor Insurance Products from Insurance Center of Monroe
Businessowners Insurance

Contractor Liability Insurance

Workers Comp Insurance


Life and Health Insurance Products from Insurance Center of Monroe
Life Insurance

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Group Health Insurance

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On-Line Workers Comp
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!
Your Personal / Company Data:

Your Name:
Your Company's Name:
Street Address:
City:
State: (Must be Michigan or Ohio)
Zip/Postal:
E-Mail (REQUIRED):
E-Mail again (for accuracy):
Phone:
Fax (optional):
 

Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type NONE)
 
List Claims & Amounts Paid
(If none, type NONE)
 
Years In Business:
 
Business type:
(proprietorship, corporation, etc.)
 

 
Underwriting Information:
 
Describe IN DETAIL,
Your Business Operations:
 
Payroll Class #1:
List Class Code # if you know it, and describe payroll class: Insert Annual Payroll in dollars for this
class here: 		$
 
Payroll Class #2: (if none, leave blank)
List Class Code # if you know it, and describe payroll class: Insert Annual Payroll in dollars for this
class here: 		$
 
Payroll Class #3: (if none, leave blank)
List Class Code # if you know it, and describe payroll class: Insert Annual Payroll in dollars for this
class here: 		$
 
 
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Insurance Center of Monroe . 428 N. Monroe Street . Monroe, MI 48162
Phone: 734-241-1333 | Fax: 734-241-1459 | E-Mail us at: quotes@goicm.com
Our Telephone Quoting Hours are: 9:00am to 5:00pm (Monday-Friday)
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