Joe Black Agency, Inc.
122 West Main Street
Salem, IL 62881
Phone: 618-548-3073         Fax: 618-548-3033



This form is to request insurance information from our agency. Provide us with your name, phone number, and/or email address, and also let us know the type of insurance you are interested in. We will be happy to contact you to discuss your options.


(use this format: mm/dd/yyyy)
Please provide the following information about yourself:

(use this format: 111-111-1111)
What type of insurance are you interested in? If you aren't sure of the type, please give a brief description of how the insurance will be used.
If you want to erase what you have entered in this form and start over, click the Reset Form button.
When you have completed this form to the best of your ability, click the Submit Form button to send the form to us.