NEW CLIENT INFORMATION SHEET
|General Information *if More than 1 location provide list - SEPERATE Sheet |
|Company Name | |
|Physical Address | |
|City | |State | |ZIP | |
|Mailing Address (if different) | |
|Phone | |Cell | |Fax | |
|E-mail Address | |
|Contact Person | |Legal Entity (Corp., Partnership,| |
| | |LLC etc.) | |
|Years in Business | |# of Employees | |FEIN | |
|Description of Operations |
| |
|Year Built | |Updated Electrical | |Updated Roof | |
|Flood Zone | Yes No |Zone | |Updated Wiring | |Updated Plumbing | |
| | | | | | | | |
| | | | | | | | |
|Sprinkler System | Yes No |Percentage | |% |
|Alarm | Yes No |Type | |
|Square Feet | |Number of Stories | |
|Property Value ($) to be Covered: |
|Building if Applicable: | |
|Business Personal Property (office contents including furniture, fixtures, tenant improvements, | |
|inventory, stock, permanently installed equipment or machinery): | |
|Contractors Equipment if Applicable: | |
|General Liability insurance Information |
|Annual Receipts (last year) | |Annual Payroll | |
|Current Year Projections for Receipts and | |Blanket Additional Insureds| Yes | No |
|Payroll | |Required? | | |
|Workers Compensation Insurance INformation |
|Federal ID #, if none social security number | |Experience MOD | | Current |
| | | | | Expired |
|Annual Payroll by Category (use separate sheet if necessary) |
|Class Code |Payroll |
| | |
| | |
| | |
| | |
| | | | |
|Signature of Authorized Client Representative |Date |
| | |
| | | | |
|Signature of Agent |Date |
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