Workers’ Comp *Name of business *FEIN# or EIN# All company partners must be listed on the policy. Company partners who are not listed on the policy must present an EXEMPTION certificate. *Do any of them have an "exemption"? YesNo *Name of partners who have an exemption certificate: *Business address apt # *City *ZIP *Is the business address the same as the mailing address? YesNo Mailing address if different from business address apt # City ZIP *E-mail *Phone number in the US *Business industry (flooring, lawncare, cleaning) *Does the business have registered employees? YesNo How many? Amount paid yearly to employees: *Does the business use subcontractors? YesNo Annual payment to subcontractors: *Business' gross annual income: *Do you have, or have you had, a Workers' Comp policy? YesNo *How did you hear about us? FacebookInstagramGrupo das MãesDealerFamily/FriendsOther Please enter their name: *Name of dealer shop: *Name of salesperson: *Please specify: Any other relevant information that was not mentioned above?
