| First Name: * |
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| Last Name: * |
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| Name of Business: |
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| Business Address Street 1: |
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| Business Address Street 2: |
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| City: |
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| Zip Code: |
(5 digits) |
| State: |
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| Daytime Phone: * |
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| Evening Phone: |
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| Email: |
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| Describe the type of business: |
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| Number of employees: |
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| Do you manufacture or sell any of your own products. If so, what products: |
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| Number of business vehicles including year, make and model: |
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| Name of current insurer: |
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| Own or rent the business location(s): |
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| Amount of building coverage requested: |
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| Amount of business personal property requested: |
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| Is there a formal safety program in place: |
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| Please mark this box with an "X" to confirm that you understand no insurance coverage is effective until you receive written confirmation from Stoll Insurance:: * |
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