Name of Company Partners/Officers/Owners Mailing Address Location Address Contact Person * Phone Number Email Address Description of Business Operations Payroll Any Business done under General Contractors license? Select One Yes No If yes, list names of GC's: Does the company use Subcontractors? Select One Yes No If yes, are Subcontractors required to have their own Certificate of Insurance? Select One Yes No Years in Business Type of Business Select One Individual Corporation LLC Partnership S-Corp Other - please fill in State(s) operating in Estimated Gross Sales Currently Insured Select One Yes No Not sure N/A - New Business Current Policy Expiration Date Interested in Payroll Services Select One Yes No Not Sure