If you are interesting in receiving a pricing indication for your eCommerce initiative, please take a minute to provide us with some preliminary information that will help us understand your requirements. A pricing indication will be returned to you within 24 hours. Thank you.

Name:

Email:

Phone:

What are you interested in? TEAM-UP Interactive upload to an existing Web site TEAM-UP Interactive upload to a web site created by Connective Traditional EDI Upload to a Legacy system

Select the LOB's you are interested in automating:

Homeowners: Personal Auto: Inland Marine: Personal Umbrella:

Workers Comp: Business Auto: Commercial Auto: Commercial Property: General Liability:

Select the source systems that you want to accommodate:

Applied: AfW: Prime2000: Sagitta:

DORIS: SIS: Other:

Select the transaction types that you are interested in automating:

Quote: New Business: Renewal: First Notice of Loss: Inquiry:

Other:

In how many states do you write business?

1:     2:     3:     4 - 10:     11 - 20:     21 - 50:

What type of system will receive the uploaded transactions:

an interactive web site (already built in-house) an interactive web site created by Connective a Legacy system via a traditional EDI transaction Other

What is the name/vendor of the system that will receive the uploads?

What platform does the system run on (e.g., AS/400, Unix, NT, etc.)?

What is the database used by your policy management system?

Additional Questions/Comments: