Financial/Insurance Associates

ERS Inc., is an Iowa targeted small business providing paramedical services to insurance and financial associates by contracting with national paramedical companies.

Agent Request Form

* Indicates a Required Field

Client Name *

Gender *

Client Address *

Work Address

Home Phone Number *

Cell Phone Number *

Work Phone Number *

Client Birthday (mm/dd/yy) *

Insurance Company *

Brokerage

Insurance Amount *

Policy Number

Insurance Type *

Policy Type *

Coverage *

Are you a smoker? *

Type of Exam Requested

Agent *

Agent Code Number *

Agency *

Agency Code Number

Agency Phone Number *

Agency Fax Number

Agency Email

Special Instructions or Requests

ERS Inc.

625 1st Avenue SW
Cedar Rapids, IA 52405

Phone: 319-369-6911
Fax: 319-369-6915
Email: ersmed@qwestoffice.net