Cyber – Privacy – Hacker Liability – Dopazo & Associates Insurance

Number of Employees

Annual Sales

Limits of Liability Desired

Do you use subcontractors?

Do you currently have insurance?

Have you had any claims?

Company Name *

Sole proprietor, corporation or LLC name

Contact Name *

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Physical Address (if different than mailing address)

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone *

Mobile Phone

Txt Msg Consent

By select YES and entering your telephone number, you expressly authorize Dopazo & Associates, Inc. (“Dopazo”) to call or text you with offers and reminders at the number you provided, including through the use of the possible use of automated technology and recorded messages. You certify that the number you provided is your own number. If you change your number, you will notify Dopazo as soon as possible. You are not obligated to provide this authorization and it is not a condition to receive a quote or purchase or renew your insurance. You may revoke this authorization at any time by remove@dopazo.com. You understand and agree that standard text messaging rates will apply to any text messages sent to you by Dopazo and that Dopazo will not be responsible for any charges for text messaging.

Federal Employer Number FEIN *

Website / URL

Acknowledgement *

I Agree

I acknowledge and understand that insurance coverage cannot be bound or changed via submission of any online form/application provided on this site or otherwise. No binder, insurance policy, change, addition, and/or deletion to insurance coverage goes into effect unless and until confirmed in writing directly by a licensed agent.

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