Company Name:  

First & Last Name:  

Street Address:  

City, State & Zip:  

E-Mail Address:  

Telephone:  

Current Insurance Information

Insurance Company Name:  

Any losses in last 3 years?:  

# of claims:  

Claim amt. pd $:  

Premium Amount:  

Policy Exp. Date:  

MOD Factor:  

Policy #:  

Describe the type of Coverage you currently have:  

Prior Carrier Info

Insurance Company Name:  

# of claims:  

Claim amt. pd $:  

Premium Amount:  

How many years with:  

MOD Factor:  

Policy #:  

About Your Business

# of Full-time:  

# of Part-time:  

Owner's Name:  

Fed Tax ID:  

License Type:  

Yrs in Business:  

License #:  

# of locations:  

Square Footage:  

Est payroll / mo.:  

Type of Business:  

Please describe your business here:  

Owners / Partner / Officers

Name

Payroll Information

General Information

Do you offer safety programs?

Do offer health benefits to majority of employees?  

Do employ any minors (under 18)?  

Operation all/part of exist. business purch/acq?  

Do you use subcontractors?  

Use any equipment that bends/shapes/forms?  

Are athletic teams sponsored?  

Been a lapse in coverage during past 12 months?  

Any work above 15 feet?  

Had a bankruptcy in past 7 years?  

Are a member of any trade organizations?  

Additional Information

:
Please provide any additional information that may be helpful in giving you an accurate quote or that you didn't have enough room for.

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