First Volunteer Insurance Agency - insurance and banking for Tennessee, Northern Alabama and Northern Georgia!

Independent Distributors Program

Mike Owen, Agent
Voice:(Toll Free) 866-668-4900 (Local) 423-668-4888
Fax: (Toll Free) 866-668-4746 (Local) 423-668-4746
Email: distributorgroup100@firstvolunteer.com

Distributor Proposal Request Sheet

Auto
(Minimum Information required to get a proposal)		(Producer Code XV538)

Company Name:		Contact Name (required field):
Voice Number (required field):		Fax Number:
Email:
Mailing Address:		Physical Street Address:
City:		State:
Zip:		County:
Proposed Effective Date:		Name of DSR:

Year:		Make:
Model:		GVW:
Cost New:	$	Radius:
V.I.N. Number:
Any tickets or accidents in the last 3 years?		yes no
If yes, explain:

Name as on Driver's License:
Driver D.O.B.
		State of Issue:

Trailer
Year:		Make:
V.I.N./Serial Number:		Length:
Cost New:	$

General Liability
Expected Annual Sales:		Payroll to others:	$
Any Losses in the past 5 Years: yes no		Is this a New Venture: yes no
Previous Insurance Carrier:		Premium:	$
Years in similar business:		Prior management experience if any:

Property
Location of Storage Building: Street:
City:		State:
Zip:
Maximum inventory you keep at all locations:		$
Building Coverage, if needed:		Area of Building you Occupy:
Sprinklered: yes no		Age of Building:
Any other Occupancies: yes no		If so what are they:
Construction of Storage Building:		Wood Frame Block Metal
Fire Department that would respond to a fire:
Would you like an Umbrella Liability Quote:		yes no
Would you like information on any other coverage:		yes no
If yes, what kind:



First Volunteer Insurance Agency, Inc. is a wholly owned subsidiary of First Volunteer Bank so we are required to make you aware of the following: FVIA products 1. Are not a Deposit of the Bank. 2. Not FDIC insured. 3. Not insured by any Federal Government Agency. 4. Not Guaranteed by the Bank. 5. May go down in value if there is investment risk.

The insurance products that First Volunteer Insurance Agency, Inc. offers our customers and customers of First Volunteer Bank are: *Not a deposit *Not FDIC Insured *Not Insured by any Federal Government Agency *Not Guaranteed by the Bank *May Go Down in Value

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