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 VFBL VAW 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
