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Fields marked (*) are mandatory.
Agent Name*
Agent Number*
Agent PH #*
Agent Fax #
Name of Business*
Name of Owner*
Type of Entity*
Federal Tax I.D. # or Social Security # ?*
Address*
Phone #*
Fax #
E-Mail*
Description/Nature of Business?*
How many years in business?
OR - How much experience in this field?
Annual Payroll*
Job Descriptions
How many Full Time employees?*
How many Part Time employees?*
Any Losses?*
Owner/Officers
Name/Names
Duties
Include/Exclude for coverage
Birth Date
This form is for indication ONLY
To obtain a full quotation, we will require the following:
Copy of existing policy declarations page required
Claims/Loss History (5 years) with Insurance Company Loss Runs
Remarks
All items marked * must be answered to recieved a response!