Atlantic Mutual Insurance

888-888-3270

  • ATLANTIC MUTUAL LEGAL DEFENSE INSURANCE COMPANY, INC.

    COMMERCIAL INSURANCE APPLICATION
  • APPLICANT INFORMATION

  • ACCOUNT INFORMATION

  • Additional Insureds to be listed on the policy

  • Required Underlying Insurance Information

  • Election of Optional Coverage

  • PREMISES INFORMATION

  • Please complete the following for each physical location or upload Acord Form 139 below

  • SIGNATURE PAGE

  • ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY ( IN FLORIDA, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).


    The undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true and complete and may be relied upon by Company in quoting and issuing the policy. If any of the information is this Application changes prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the quote or binder.

  • Signing the form below will automatically submit the application.
  • By clicking submit below, the application will be emailed to the insured to request their signature.

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