Thank you for your interest in Encompass Insurance. Please take a minute to provide the following information so that the independent agent that you have chosen to contact you will be better able to serve your needs.

Fields marked with an * are required.
Your Contact Information
How did you hear about us?*
Are you a current Encompass Policyholder who is moving?
First Name:*
Last Name:*
Phone:*
- -
Best Time to Call:*
E-Mail Address:
Street Address:
Post Office Box or Apartment Number:
City: State:* Zip Code:
I am interested in:(select as many as apply)*
What is your current auto policy expiration date?
Month: Day: Year:
What is your current homeowner policy expiration date?

Month: Day: Year:
Current Insurance Company:
Additional Comments:
Any information you provide via this form is strictly confidential. By submitting this form, you authorize Encompass Insurance to provide your information to the independent agent that you have chosen to contact you.
Find another Agent

Disclaimer

For your protection, Encompass Insurance requires a personal conversation between you and the independent agent that you have selected and asked to contact you prior to binding any coverage or changes in coverage. This means that coverage cannot take effect until this conversation occurs.

Completing this form does not constitute an application for insurance. Communicating via e-mail does not constitute an offer of coverage. Coverage is subject to availability and qualifications. Other terms and conditions may apply.

Encompass Insurance reserves the right to declare any material received to be the intellectual property of Encompass Insurance upon receipt of the information or material in any form.