The PMA Insurance Group -- Request more Information on Groups & Programs

Please help us understand your needs by completing the following form. A PMA Insurance representative will contact you. There is no obligation.

* required field
General Information
Name of Program:
Target Date:
*Agency Name:
*Street Address:

*City:
*State:
*Zip:
*Primary Contact:
Title:
*Phone:
Fax:
*Email:
Website:
Overview of Program:
Describe agency expertise with this type of business:
Describe business plan with premium objectives over the next 12 months:
Currently Appointed with PMA?
Currently Established Insurance Program?
Is there Currently a Dividend Available?
If Yes, Please Describe:
Classes of Business in Association (SIC or WC Codes):
Geographic Territory
Please Outline Premium Coverage by State:


Insurance Information
Expiration Date:	Concurrent:
What Funding Mechanism is of Interest: (1st Dollar, Captive, SIG etc.)

What issues would cause you to change your current program?

What Processes/Services will be provided by the Agency?