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PRIVACY NOTICE: THE INSURANCE SHOP DOES NOT DISCLOSE, SELL, OR TRANSFER ANY INFORMATION ABOUT OUR VISITORS. 

YOUR INFORMATION IS SHARED WITH INSURANCE RELATED ENTITIES FOR THE SOLE PURPOSE OF UNDERWRITING & QUOTING.

ABOUT YOU

Your Name:

Title/Position:

Email:

Phone:

     Fax: 

ABOUT YOUR BUSINESS

Company Name:

Years in Business:

          Business Type:  Select Individual Partnership LLC S-Corp C-Corp Other     

Complete Address:

Address City, State Zip

Employee Count:

          Fed Tax ID:  social security if no Fed ID Number

Gross Annual Payroll:

estimated            Work Comp Mod: if known

If Known Class Code 1:

          Estimated Payroll for Class Code 1: 

Class Code 2:

          Estimated Payroll for Class Code 2: 

Class Code 3:

          Estimated Payroll for Class Code 3: 

Additional Codes/Payroll:

if any

Owner Information:

1) Owner Names 2) Include or Exclude for Coverage

Any Claims Last 3 Years:

(if yes, please describe)

Please Describe

Your Business:

Please List Any Other Lines of Coverage Needed:

Do You Use a Payroll Company:

Yes No     If yes, Which Company:  

Current Carrier:

     Current Premium:  

Remarks/Needs/Comments:

if applicable: I-Shop Broker:

optional

OPTIONAL FILE UPLOADS

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