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Business Information
Business Name
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City
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ZIP / Postal Code
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Primary Phone Number
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Fax Number
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E-Mail Address
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Business Type
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Industry
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Describe your Business
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Annual Gross Sales
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Number of Full Time Employees
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Number of Part Time Employees
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Estimated Monthly Payroll
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Number of Locations
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Years in Business
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Federal ID #
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Business Type 2
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License Number
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Owners/Partners/Officers( Include yourself if applicable)
Number of Owners/Partners/Officers
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Owner 1
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Last Name
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Date of Birth
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Title
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Ownership %
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Owner 2
Owner Name (First, Last)
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Date of Birth
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Title
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Ownership %
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Owner 3
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Date of Birth
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Title
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Ownership %
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Owner 4
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Date of Birth
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Title
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Ownership %
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Owner 5
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Title
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Ownership %
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Payroll Information
Employee Group
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Payroll Rate
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Annual Payroll
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Misc. Information
Do you offer safety programs?
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Do you offer health benefits?
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Do you employ any minors?
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Do you use sub-contractors?
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Do you use any equipment that bends/forms/shapes?
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Do you sponsor any athletic teams?
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Do you do any work up over 15 feet?
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Is the business open 24 hours?
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Is the business involve any deep frying of foods?
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Is the business involve any filling of propane tanks?
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Have you filed bankruptcy in the past 7 years?
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Are you a member of any trade organization?
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Do you have operations outside the state where you are domiciled?
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Coverage Information
Current Carrier Name
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Policy Expiration
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Current Policy Premium $
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MOD Factor
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Coverage Description
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Has coverage lapsed in past 12 months?
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New Coverage Liability Limit
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Losses/Claim
Number of Losses Claimed in Past 5 years
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Additional Information
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