EmailMe Form - Bad Debt Insurance Request Form

Please Note

To be eligible for coverage, Insurance MUST be in place prior to an order being shipped AND you must have a valid purchase order from your customer for the order.

Insurance is NOT in place with The until you receive email confirmation from us that the client is insurable and we have received an endorsement for your client to our insurance policy. NOTE: Not all clients are insurable!

For a detailed description of the costs and overview of the insurance program, Click Here.

Your Information

Your Name *

Your Email *

Your Sales ID *

Your Phone *

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Your Fax

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Client Information

Client Legal Name *

Client DBA Name (if applicable)

Client Corporate Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Client Billing Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Client ID *

Requested Coverage Amount *

Payment Terms for this client *

Client DUNS Number

Comments or Notes: