DOI # 0429039

This is an application only, and does not bind coverage (see disclaimer below).

Name

Business name

Address

City St. Zip

Pho Fax Email

If you do not want to complete the rest of this application, fax, or email us the above and we will contact you.

This is a sole proprietorship a partnership a corporation LLC

Federal employers ID #

How many years in business?

Do you have more than one location? Yes No

If yes address of other locations

Do any of your employees ever go out of state? Yes No

Do you employ any relative or people under 16 yrs. of age? Yes No

Do you have insurance now? Yes No

If yes company name

Policy number expires

Do you know your experience modification? Do you have your loss runs, or can you get them? yes no

Are you member of any trade association? Yes No

If yes name of association

How many employees do you have?

What is your primary job classification?

code annual payroll

What is your secondary classification

code annual payroll

What is your total estimated annual payroll?

How may employees do you have?

Full time Part time

Names of any excluded employees excluded from coverage.

Why are they to be excluded?

DISCLAIMER: No coverage is provided until an application signed by the applicant, and other necessary information and required payment are received, and the application is accepted by the insurance carrier to whom was submitted.

All applications are subject to further underwriting, which may or may not effect the rate, by the insurance company to whom it was submitted. We will attempt to notify you of any rate increases, when they become known to us.

Boy am I glad this is over.