FORM - P & C

Agent Information for Primary Writing Agent / Broker:

Name: Louie (Lew) Thompson, Agent / Broker

Local: (229) 337-4727

Toll Free: (800) 297-0817

Email: lewthompson3@gmail.com

Website: www.brookridgebenefits.com

Address: 3698 Inner Perimeter Rd #2496 - Valdosta, GA 31604

Only Required for Business Policies

Please take a picture of all Drivers License of any Drivers you would like listed on your Policy

If you would like to list anyone else on the policy as a driver, please provide their information here.

Like most insurance companies, information from you and other sources, such as your driving, claims and credit histories, to calculate an accurate price for your insurance. New or updated information may be used to calculate your renewal premium. We agree to protect your personal information and how you may access and correct it. We can provide a copy at your request.