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Workers Comp / Employer Liability
Company Name
*
Date
*
Name of principle
*
Address
*
City, State, ZIP
*
Phone
*
Fax
Email
*
How did you hear about us?
Buisness Type
\n
Corporation
Partnership
Sole Proprietor
Number of officers
Do you want to exclude Officers ?
\n
Yes
No
Contractors State License Number
Years Experience
Are you insured now?
\n
Yes
No
If yes, with whom?
Expiration Date
Description of Operations
What is the annual gross sales for your business?
Number of exployees?
Part Time
Full Time
Amount of hourly wage
What is the estimated annual payroll for this year?
How does it divide into?
Commercial
Residential
Is there any other coverage you are interested in?
G
eneral Liability
C
ommercial Auto
P
roperty Insurance
B
onds
W
orkers Comp
N
one
How soon do you need your insurance to start?
\n
Immediately
One Week
One Month
Other
If other, please state
Can you provide 3 years loss runs?
\n
Yes
No
Which class codes will you be using?
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