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 *


    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