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Convenience Store - Workers Compensation Form


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Company Information
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First Name
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Last Name
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Street
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City
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State
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ZIP / Postal Code
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E-Mail Address
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Primary Phone Number
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Alternate Phone Number
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Federal ID or SSN:
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State Unemployment Number:
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Breakdown of Ownership:
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Are owners to be included or excluded?
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Years in Business:
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Years Experience:
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Number of Employees:
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Annual Employee Payroll
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Do you currently have insurance?
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Current Insurance Provider
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Have you been cancelled/non-renewed?
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If yes, list the reason:
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Losses in past three years:
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Is health insurance provided for employees?
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

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Judy Carter & Associates   300 Vestavia Parkway   Suite 1600   Birmingham, Alabama 35216