Where connections make a
difference.
402-434-7200
info@unicogroup.com
Contact Us
Careers
Locations
Report a Claim
Home
About
Our Story
Careers
Locations
Contact Us
Newsroom
Our Products
Business Insurance
Property Insurance
General Liability Insurance
Commercial Auto Insurance
Umbrella Liability
Cyber Liability
Management Liability
Loss Control and Safety Management
Workers’ Compensation
Claims Advocacy
ModMaster
Industry Specific Programs
Insurance for Self-employed Entrepreneurs
Special Event Insurance
Employee Benefits
Group Health Plans
FSA and HSA
Additional Benefit Options
Voluntary Benefits
Medicare
Individual and Family Health Insurance
Personal Insurance
Home Insurance
Renters Insurance
Personal Umbrella Liability
Auto Insurance
Motorcycle Insurance
Boat Insurance
Life Insurance
Individual and Family Health Insurance
Medicare
Weddings, Parties and Social Events Coverage
HR and Safety Solutions
Industries
Construction Insurance
UNITEL Telecommunications Insurance
Risk Management Services
UNITEL Communications Benefits Program
Trucking
Nonprofits and Social Services Insurance
Pivots and Irrigation Insurance
Financial Institutions
Manufacturing
Healthcare
Search for:
Personal Insurance Broker Intake
Agency and Insured Information
Agency Name
(Required)
Named Insured(s)
(Required)
First Name
Last Name
Add
Remove
Click the + on the right-hand side to add additional named insureds.
Insured(s) Mailing Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Carrier Name
(Required)
Policy Number(s)
(Required)
Is this an auto policy?
(Required)
Yes
No
Driver Information
(Required)
Driver First Name
Driver Last Name
Driver Date of Birth
Driver's License Number
Add
Remove
Click the + on the right-hand side to add additional drivers.
Δ
✕
Cart
