• SECTION A –(Required)

  • Business Info

  • Annual Revenues past 12 months and/or Projected Revenues next 12 months

    Lessor or owner of location (If owner please complete Section B)

    # Full time employee’s# Part time employee’s

    Annual Payroll for all W2 Employees (Excluding owners)

    Current Insurance company Renewal date Annual Premium$

  • Section – B- Property/Building Coverage (Optional)

  • Year of updates to

  • SECTION C –Workers Comp (Optional)

  • EMPLOYEES

  • Types of Labor Performed

  • Total Estimate payroll for this group

  • SECTION D COMMERCIAL AUTO (Optional)

  • Vehicles

  • Should be Empty: