Hollis Insurance Agency, Inc.

1 Village Green North, Suite 121
Plymouth, MA 02360

Phone: 508-209-0400     Fax: 508-209-0444

Please be advised that insurance coverage cannot be bound, modified, or terminated by e-mail messages or information provided to us via the web. Any information you submit will be used solely for the purpose of quoting insurance options, and does not in any way constitute an agreement of coverage.

Binder Request Form

Our Customer/Name Insured:
Effective Date of Binder (DD/MM/YY): //

Your Information

Condo Association Name (if applicable):
Full Name:
Company:
Email:
Phone: Ext:
Fax:

Mortgage Company Information

Mortgage Co. Name:
Address:
City:
State:
Zip:
Mortgage: First   Second
Prefer:
Additional Info/Comments: