Worker Compensation Insurance
Commercial Equipment/Inland Marine
Long Term Care
Legal Company Name (As filed with the state)
DBA Company Name
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Not For Profit
Company Phone Number
Contact Mobile Phone Number
Company FEIN or Tax ID
NAICS or SIC Code
Year Business Founded
Requested Effective Date of Policy(s)
How Many Owners In The Business?
Description of Business
Revenue For Most Previous Fiscal Year
Forecasted Revenue For This Fiscal Year
# of Employees
Current Approximate Premium
# of Locations (Address for each including county and zip code)
# of Additional Interests (Name, Address and type of interest for each AI (Additional Insured, Co-Owner, Lienholder, Loss Payee, Mortgagee, Trustee, Owner, Other (Please describe in detail)) If more than 2 please email at firstname.lastname@example.org
Do You Have Employers’ Liability?
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