| About
Your Business |
|
Sole Proprietor Partnership
Corporation LLC Association |
Do
you currently have Workers
Compensation
insurance?
Yes No |
| If
"Yes", when does your current policy expire? |
|
If "Yes", who are you currently insured with? |
|
Type of Business |
Description
of Business Operations:
|
|
Year Business Established |
|
Years at Current Location |
|
|
Number of Locations |
|
|
Number of Company Vehicles |
|
Approximate Annual Gross Revenue |
|
Approximate Annual Payroll * |
|
Approximate Amount of Desired Insurance |
Have
you been named in a lawsuit in the last
year?
Yes No |
If "Yes",
briefly explain:
|
 |
| Optional coverage (check the ones you may want) |
| |
| Details |
| When would
you like to be contacted?
Morning
Afternoon
Evening
Any Time
|
Any
Comments / Questions?
|
