|
Business Name:
|
|
|
Email Address:
|
|
|
Business Address:
|
|
|
Phone Number:
|
|
|
Fax Number:
|
|
|
Business Website:
|
|
|
Entity Type:
|
|
|
FEIN Number:
|
|
|
How Long in Business:
|
|
|
Years Prior Experience:
|
|
|
Number of Locations: (please provide addresses for additional locations)
|
|
|
Additional locations:
|
|
|
State(s) of Operation:
|
|
|
Name(s) of Owner(s)/Officer(s):
|
|
|
Describe Your Operations:
|
|
|
Annual Receipts/Sales - Current Year:
|
|
|
Previous Year:
|
|
|
Do you have Employees?
|
Yes
No
|
|
If Yes, how many:
|
|
|
Total Annual Payroll:
|
|
|
Do you offer Group Health Insurance to your employees:
|
Yes
No
|
|
If Yes, Name of Carrier:
|
|
|
Do you have Workers' Compensation in force:
|
Yes
No
N/A
|
|
If Yes, please provide the following:
Carrier Name, Expiration Date, Premium:
|
|
|
Do you currently have General Liability/Property Insurance coverage:
|
Yes
No
|
|
If Yes, please provide the following: Carrier Name, Expiration Date, Premium:
|
|
|
How many years of prior, uninterrupted insurance coverage:
|
|
|
Have you been involved in or aware of any claimes:
|
Yes
No
|
|
If Yes, please explain:
|
|
|
Were you referred by someone? If yes Please list who referred you:
|
|
|
|