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Agency Information

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First Name *

Last Name *

E-Mail Address *

Phone

Applicant Information

Applicant Name *

Physical Address *

City/State *

ZIP / Postal Code *

FEIN *

Business Entity Type

Underwriting Information

Effective Date *

Class Code/Estimated Payroll *

Class Code/Estimated Payroll

Employers Liability Limit

Deductible Amount

Detailed Description of Operations *

Years in Business

New Venture/No Prior

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Any Lapse in Coverage or Non-renewal

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3 year loss ratio less than 50%

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Any Use of Subcontractors?

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If yes, please provide percentage of work provided by subs.

Any work in states other than GA?

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