Printer-friendly versionPrinter-friendly version

Back to Express Requests

Inland Marine Express Request

*Complete and submit the form below for an Express Premium Indication from OGA’s Small Business Unit

Fax: 405.840.9388 | 800.771.8116
Phone: 405.840.9393 | 800.299.1951

Agency Information
Applicant Information

Include 3 year loss history

Schedule of Property

*Note: To bind, make, model, and serial number are required.

Please list each item as:
Item | Manufacturer | Model Year | Description (serial # needed to bind) | Limit of Insurance | Deductible

$
Please Note

*Fully completed Acord applications and any applicable supplemental questionnaires are required prior to binding. Please note that the premium indication is subject to change upon receipt of the Acord and any required supplemental.

If needed, please include any comments or additional information here.

CAPTCHA
This question is for testing whether you are a human visitor and to prevent automated spam submissions.
Image CAPTCHA
Enter the characters shown in the image.
Wholesale & Specialty Insurance Association Independent Insurance Agents of Oklahoma Oklahoma Surplus Lines Association