| Your Full Name: |
|
Tel: Email: |
| Business Name |
|
Federal ID
Number
|
| Number
of Owners |
|
Percentage of
Ownership |
| Number
of Locations |
|
Annual Gross receipts
|
| Mailing
Address: Street |
|
City
|
| Which
state is your main office located at: |
|
Zip
Code
|
| Do you
have employees in other states? |
|
Yes
(If yes please select this) |
| Year
business started:* |
|
|
| Are you
currently insured? |
|
Yes (If yes please select this) |
| If yes,
name the current carrier: |
|
|
| Current
Policy: |
|
Number
Renewal Date
|
| Any
claims in the last 5 years: |
|
Yes (If yes please select this) |
| Select
your business legal entity? |
|
|
| What
industry is your company in? |
|
|
|
Give specific detail on the
nature of business/what do you do? |
|
|
|
| Does
your business offer health insurance to the employees? |
|
Yes
|
| Please
list your most recent calendar year gross payroll: |
|
|
| # of Full Time Employees:* |
|
|
| # of Part Time Employees:* |
|
|
| # of Subcontractors:* |
|
|
|
| Other information your agent should know: |
|
|
| |
|
|
