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Quote Needed By:
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Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
Producer
Agent to Email Quote Form to
Dianne Joyce
Keyla Craven
Patricia Ross
Stacy Martin
Tiffany Kitchen
Insured's Info
Insured
Phone Number
Email
Mailing Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands (US)
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
State
ZIP Code
FEIN/SSN
Years in business/experience
Description of Ops
Owner(s) & DOB
Gross Revenue
Total Payroll
# of FT Employees
# of PT Employees
Current Carrier & Policy Number
Losses
Policy Info
Total # of Employees
FT
PT
Short Answer
Code
Description
# of Employees
Payroll
$
Code
Description
# of Employees
Payroll
$
Code
Description
# of Employees
Payroll
$
Code
Description
# of Employees
Payroll
$
Current Experience Mod
Attach Mod worksheet from NCCI
Current Carrier
Attach Loss Runs for the last 3 years
Yes
No
File
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QUESTIONS
Non-Renewed or Cancelled?
Yes
No
Explain
*
Any bankruptcy within 5 years?
Yes
No
Explain
*
Judgement of Lien within 5 years?
Yes
No
Explain
*
Any other operations?
Yes
No
Explain
*
Any watercraft or docks?
Yes
No
Explain
*
Any pools or lakes?
Yes
No
Explain
*
Any special events?
Yes
No
Explain
*
Any out of state operations?
Yes
No
Explain
*
Any alcohol sales?
Yes
No
Explain
*
Any subcontractors?
Yes
No
What % and type of work?
*
Notes
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