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Insurance Forms Order Application

You may complete this form and send it to us using our secure server by clicking on the "Submit" button below
or you may fill in the information, print the form from your browser window by clicking on the Printable Version button above, and mail or fax the form to:
MJ Consulting & Netservices, LLC, 1507 North Main Street, Oshkosh, WI 54901
Fax: 0075

* Denotes Required Field

General Information

*Business Name:
*Contact Name:
   Position:
*Address:
*City:
   *State:   *Zip Code:
*Business Phone:
  *Fax:   Ex. 920-555-1212
*Contact E-Mail Address:
*Confirm E-Mail Address:

Payment Information

This online application is on a secure server
An invoice will be sent via regular mail after your order is complete

Web Site / E-Mail Information

Please give the domain name (URL) in which this insurance Web site content will be hosted: http://
For quote forms and customer service forms orders, please list the e-mail address at your business in which you want client submissions (quote requests and service requests) sent:
Do you wish to use the same background color or image from your Web site for your custom content?:
Do you wish to use a graphic logo from your Web site for the top of your custom content?:
If "Yes," please describe the logo or give the file name/location on your Web site:

Online Insurance Forms Selection

Online Personal Insurance Applications Section

All personal insurance application forms involve a one-time charge of $40.00 per form.
Please select the forms you wish to purchase.
Annuity
Automobile
Aviation
Boat/Watercraft
Condo Owners		 Disability
Flood
Health
Homeowners
Inland Marine		 Life
Long-Term Care
Medicare Supplement
Mortgage 		Motorcycle/ATV
Pets
Renters
Umbrella
 

Online Commercial Insurance Applications Section

All commercial insurance application forms involve a one-time charge of $40.00 per form.
Please select the forms you wish to purchase.
Automobile
Aviation
Business
Business Owner's Package (BOP)
Contractors		 General Liability
General Liability & Property Combined
Hotel/Motel Owners
Janitorial (Commercial/Residential) 		Premium Indicator
Professional Liability
Property
Restaurant 		Simplified EPL
Special Events
Umbrella
Workers' Compensation
 

Online Group Benefits Insurance Applications Section

All group benefits insurance application forms involve a one-time charge of $40.00 per form.
Please select the forms you wish to purchase.
Health      
 

Online Bond Forms Section

All bond forms involve a one-time charge of $40.00 per form.
Please select the forms you wish to purchase.
Automobile Dealers
Contractors		 Dishonesty
General (Miscellaneous) 		Janitorial Services
License		 Pension Trust
Probate
 

Online CSR Forms Section

All CSR forms involve a one-time charge of $40.00 per form.
Please select the forms you wish to purchase.
Agent of Record Request
Automobile ID Card Request 		Automobile Policy Change
Automobile Loss Notice 		Certificate of Insurance Request
Property Policy Change 		Property Loss Notice
Renewal Notice Reminder

Content Delivery

Your insurance Web site content will consist of HTML files and scripting files, which need to be added to your Web site.
This content is ready to use, with no programming or setup required.
How do you wish to receive your content?:
If you chose to have your content delivered via direct FTP to your Web site, we will only be
able to do so if you can provide a username, password, and FTP address from your ISP.
This also includes the addition of links from your existing pages to your new content.
User Name:
Password:
FTP Address:
Will Send This Information Later (please check this box if you do not currently have the information available)

Feedback
Please check this box if you would like a representative to call you and discuss your order
 
Would you like an e-mail sent to you whenever we add new insurance Web site content?:
 
If there is any particular insurance-related content you would like for us to add to our site and/or services, please enter it below:

Additional Comments

Please provide any additional comments that you feel would be appropriate for this order. If you have additional information to provide, where there were not enough fields above, please enter it here

Order Confirmation

Please click on the "Submit" button below to place your order. You will receive an e-mail within one day verifying your order.