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TYPE OF ENTITY:

  Select Individual Partnership Corporation LLC 503(c) Non Profit

DESCRIPTION OF BUSINESS/OPERATION:
 YEARS IN BUSINESS:       STATE LICENSE NUMBER:

ANNUAL SALES:                  ANNUAL PAYROLL:  

NUMBER OF FULL TIME STAFF:      NUMBER OF PART TIME STAFF: 

CURRENT INSURANCE CARRIER:
# CHILDREN UNDER 2 YEARS:       # CHILDREN 2 YEARS AND UP:

COVERAGE’S REQUESTING QUOTE FOR:

ADDITIONAL INFORMATION:

How did you hear about us?   Select One Radio or Newspaper Direct Mail Telemarket-Lori Telemarket-Other Referal from Friend Found us on line by search Phone Book-Aardvark Phone Book-Isner Central Ohio Insurance Agency

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