Initial Submission Request | Upland Capital Group

Initial Submission

Request

The purpose of this form is to submit initial information required for our underwriters to begin their process. Once we have received this completed form, a dedicated underwriter will contact you for the next steps and any additional questions.

Initial submission requests can also be emailed to submissions@uplandunderwriters.com.

*Required Information

Submitting Brokerage Company: *

Submitting Broker: *

Broker Email: *

Broker Phone: *

Named Insured: *

Mailing or Premises Address: *

City: *

State: *

Zip: *

Named Insured Phone: *

Effective Date Expiration Date: *

New or Renewal to Upland

Description of Operations:

Upland Underwriter (if applicable):

Line of Business:

Limits Requested:

Additional Information

File Upload/s

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