National Car Wash Insurance


Home	About The Program	Quote Request	Resources	Contact Us	Mang Insurance

Please complete and submit the form below.
If you are having difficult completing the form, you may print out
a quote request form and fax it to (518) 383-3642

Supplemental Information Form (Car Wash Profile)

Name of Car Wash
Contact Person
Email Address
Telephone Number
Fax Number
Number of Locations
Location Address complete 1 form for each location
City
State
Zip
# Years in Business
Current Ins. Policy Expiration Date
Value of Building
Value of Contents
Value of Equipment
Type of Construction
Roof Support
Age of Building
# Stories
Square Footage
Alarm
Primary Type of Wash
Annual Location Receipts
# Full Time Employees
# Part Time Employees
Umbrella Limit
Drive Non-Owned Autos ?
Do you Hire Autos ?

The National Car Wash Insurance Program is a service of	Existing Clients Log In Here	Mang Insurance Agency 56 Clifton Country Road, Ste 202 Clifton Park, New York 12065 Toll Free: (800) 891-9274 Phone (518) 383-2910 Fax (518) 383-3642