General Information Questionnaire

This form is not an application for insurance. Once this form is completed and sent to us, you will be contacted by a member of our licensed, friendly, professional sales staff to discuss your specific insurance questions and needs. No coverage will be assumed bound or covered until written confirmation is received from Hartland Insurance Group.

    NFIB Member?

    I am interested in the following coverage:

    Check all that apply:

    By submitting your information, you agree to the following terms:

    Insurance Coverage cannot be bound or changed via submission of this online form/application, e-mail, voice mail or facsimile. No binder, insurance policy, change, addition, and/or deletion to insurance coverage goes into effect unless and until confirmed directly with a licensed agent and or your insurance company.

    Note any proposal of insurance we may present to you will be based upon the values developed and exposures to loss disclosed to us on this online form/application and/or in communications with us. A proposal is not an insurance policy. Please refer to the actual policy for coverage limits, definitions and coverage exclusions.