Florida Automotive Industry Association

Insurance Quote Request

For us to provide you with an accurate quote, please fill in all fields below to give us a general idea of your companies needs. Simply press 'send form' at the bottom after all feilds have been completed.

Thanks for taking the time to tell us about your company.


Name of Business:
Contact Name:
Type of Business:
E-mail Address:
Address:
City:
State/Zip:
Phone:
Fax:
On Going Health Conditions:
Total # F.T. Employee:
# Employee Insured:
Current Insurance Co.:
Renewal Date:


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Are there full time employees without medical coverage?	Yes	How did you find out about FAIA?