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|
Your
company name: |
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| Mailing
address: |
|
| Are
you a sole proprietor:
Corporation:
Partnership:
Other:
|
| Years
in business: |
|
| Contact
person: |
|
| Phone
number: |
|
| Fax
number |
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| Company
website address: |
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| Contact
e-mail address: |
|
| Type
of business: |
|
| Description
of business/operations: |
|
| Actual
property address if different from mailing address: |
|
| Federal
Tax ID Number: |
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| Existing
insurance carrier name if any: |
|
| Existing
policy number (if any): |
|
| Any
losses last 5 years: Yes:
No:
. |
| Describe
losses: |
|
| 1)CEO's
name, % ownership of company: |
|
| 2)President's
name, % ownership of company: |
|
| 3)Other
owners/stockholders name that is active in the company, %
ownership: |
|
| 4)Other
owners/stockholders name that is active in the company, %
ownership: |
|
| Annual
clerical/admin/ payroll: $ |
for that class |
| Annual
software developers payroll: $ |
for that class |
| Annual
outside sales payroll: $ |
for that class |
| Annual
other payroll: $ |
|
| Any
Special Instructions: |
|
| How
did you hear about ABC Insurance? |
|
| For
your records, please print this page. When the application
is complete, click below to submit to ABC Insurance. |
| |
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|
