Obtaining Rates

To obtain a proposal, simply complete the form below and click the "Rate Request" button.

We'll do the rest.

Licensed Agents

Paul Pomerleau, President
paul@industrialinsuranceservices.com

Chuck Pomerleau, Vice President
chuck@industrialinsuranceservices.com

Rate Request Form


	Company Name:
	Contact Person:
	Contact Phone:
	Contact email:

	Employee	Age or DOB	Male / Female	Employee Only / Employee & Children / Employee & Spouse / Emp. & Spouse & Children	Income or salary (if disability or income based life is provided)

1.			MF	Emp. Spouse Children
2.			MF	Emp. Spouse Children
3.			MF	Emp. Spouse Children
4.			MF	Emp. Spouse Children
5.			MF	Emp. Spouse Children
6.			MF	Emp. Spouse Children
7.			MF	Emp. Spouse Children
8.			MF	Emp. Spouse Children
9.			MF	Emp. Spouse Children
10.			MF	Emp. Spouse Children
11.			MF	Emp. Spouse Children
12.			MF	Emp. Spouse Children
13.			MF	Emp. Spouse Children
14.			MF	Emp. Spouse Children
15.			MF	Emp. Spouse Children
16.			MF	Emp. Spouse Children
17.			MF	Emp. Spouse Children
18.			MF	Emp. Spouse Children
19.			MF	Emp. Spouse Children
20.			MF	Emp. Spouse Children

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