If you have any questions about your benefit plans, please don't hesitate to or call Kristen Garry at 267.794.3010.

To learn more about Gallagher Benefit Services visit tccgroup.com.

To learn more about the Cultural Alliance visit philaculture.org

Individual Long Term Care

Insurance Questionnaire

(All Information is Confidential)

To furnish the appropriate product and quotation for you at the potentially lowest possible cost, please complete the following questionnaire. * denotes a required field.

I. Your Information

Name of Organization *

Address *

Contact Name *

Phone *

Fax

E-mail *

Names of Subsidiary
Organizations and
Trade Names

 

II. Company Information

1.

Number of Employees

2.

Total Annual Budget

3.

Number of Vehicles

Owned: Leased:

4.

Agency Services
Adoption Residential
Community Arts Program SCOH
Day Care School (K-8)
Foster Care Secondary School
Mental/Behavioral Health Senior Center
Museum Shelter Facility
Performing Arts Theatre
Preschool Visual Arts

5.

Other Services
 

III. Insurance Information

1.

Workers' Compensation
Current Carrier:
Renewal Date:

2.

Property
Current Carrier:
Renewal Date:

3.

General &
Professional Liability
Current Carrier:
Renewal Date:

4.

Commercial Auto
Current Carrier:
Renewal Date:

5.

Commercial Umbrella
Current Carrier:
Renewal Date:

6.

Directors & Officers
Current Carrier:
Renewal Date: