Request a Quote Municipal Entity* Entity Type City County Village Town Fire Co., Dept. or District – PAID Fire Co., Dept. or District – VOLUNTEER Volunteer Ambulance Public Library School or BOCES District Authority Commission Agency Other Other Entity Type Coverage type(s) needed (check all that apply) Workers’ Comp Volunteer Firefighter Benefit Law Volunteer Ambulance Workers Proposed Effective Date* MM slash DD slash YYYY to the 1st of Quote Needed By* MM slash DD slash YYYY Primary ContactName* Title* Phone* Email Broker Information (if applicable)Insurance Broker Broker Contact Name Broker Contact Email What is your primary interest in the PERMA program? Price Service PERMA's Reputation Unhappy w/ current provider Other Additional Notes
