IMA
This form is designed to make sending a request for a proposal as easy as possible. Complete the requested information and check the appropriate boxes, then click on the submit button at the bottom of this page.
Specific Deductible: $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $40,000 $50,000 $60,000 $70,000 $100,000 Other:
Specific Contract:
Aggregate Contract: 12/12 12/15 15/12 24/12 PAID
Please select the following options:
Attached Separate
Currently Fully Insured
Currently Partially Self-funded
PO BOX 534 Richfield, OH 44286 Phone: 1-866-862-6935