BUSINESS INFORMATION
*Business Name		*Partners / Owners	Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25+
*Legal Entity	Select Sole Proprietorship Partnership LLC S Corporation C Corporation Other	*Full time Employees	Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25+
*Years in Business	Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25+	*Part Time Employees	Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25+
*Annual Revenue	Select Under $100,000 $100,000 - $500,000 $500,000 - $1,000,000 $1,000,000 - $5,000,000 $5,000,000 - $10,000,000 Over $10,000,000	*Sub Contractors	Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25+
*Type of Business	Select Not Listed Administration Agricultural Production Agricultural Services Amusement & Recreational Services Apparel & Accessory Stores Apparel & Other Textile Products Auto Dealers & Service Stations Auto Repair, Services & Parking Building Materials & Garden Supplies Business Services Chemicals & Allied Products Coal Mining Communications Depository Institutions Eating & Drinking Places Educational Services Electric, Gas & Sanitary Services Engineering Environmental Quality & Housing Executive, Legislative & General Fabricated Metal Products Finance Fishing, Hunting & Trapping Food & Kindred Products Food Stores Forestry Furniture & Fixtures Furniture & Homefurnishing Stores General Building Contractors General Merchandise Stores Health Service Heavy Construction, Except Building Holding & Other Investment Offices Hotels & Other Lodging Places Industrial Machinery & Equipment Instruments & Related Products Insurance Agents, Brokers & Service Justice, Public Order & Safety Leather & Allied Products Legal Services Lumber & Wood Products Manufacturing Industries Membership Organizations Metal Mining Miscellaneous Repair Services Miscellaneous Retail Motion Pictures Museums, Gardens National Security & Intl. Affairs Nonclassifiable Establishments Nondepository Institutions Paper & Allied Products Passenger Transit Personal Services Petroleum & Coal Products Pipelines, Except Natural Gas Primary Metal Industries Printing & Publishing Private Households Railroad Transportation Real Estate Rubber Products Security & Commodity Brokers Services, Nec Social Services Special Trade Contractors Stone, Clay & Glass Products Textile Mill Products Tobacco Products Transport By Air Transportation Equipment Transportation Services Trucking & Warehousing Us Postal Service Water Transportation Wholesale Trade
*Property SqFT	If Applicable

BUSINESS INSURANCE TYPE		EMPLOYEE BENEFITS
	Check all that apply		Check all that apply
	General Liability		Group Health
	Commercial Auto		Group Life
	Commercial Property		Group Disability
	Professional Liability (E & O)		401K / Retirement Plans
	Business Owners Liability
	Workers Compensation

CONTACT INFORMATION
*Last Name		*First Name
*Business Address
*City		*State
*Zip		*Phone
Alt. Phone		*Email
Comments
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