Name of Business

First Name

Last Name

Address

City

State StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelewareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOreganPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Email Address

Phone

FEIN or SS#

Owner(s) / Officers:

# Active?

Are Owners to be included or Exempt? Are Owners to be included or Exempt?YesNo

Officer/Owner Duties:

Years of Experience

Date Business Started

Annual Gross Receipts (Previous Year)

Annual Gross Receipts (Current Year)

How Many W2 Part Time Employees?

How Many W2 Full TimeEmployees?

Employee Only Payroll: $

W2 Employee Duties

#1099 Employees - Part Time

#1099 Employees - Full Time

1099 Payroll: $

1099 Employee Duties:

Insured Subcontractor Cost: $

Uninsured Subcontractor Cost: $

Subcontractor Duties:

Prior Insurance Company

Expiration Date

Any Claims? Any Claims?YesNo

Please Describe Previous Claims

Limits Requested Limits Requested$100,000 Per Employee Accident / $500,000 Policy Per Disease / $100,000 Per Employee Disease$500,000 Per Employee Accident / $500,000 Policy Per Disease / $500,000 Per Employee Disease$1,000,000 Per Employee Accident / $1,000,000 Policy Per Disease / $1,000,000 Per Employee Disease

Description of Operations