Request a Quote Entity Name*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 TypeCoverage 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 ofQuote Needed By* MM slash DD slash YYYY Primary ContactName*Title*Phone*Email Broker Information (if applicable)Insurance BrokerBroker Contact NameBroker Contact Email What is your primary interest in the PERMA program? Price Service PERMA's Reputation Unhappy w/ current provider Other Additional Notes View Membership Application
