• Submission Requirements
• 1) Currently valued loss runs for the last 5 years
• 2) Waiver or Rental Agreement
• 3) Daily Safety Checklist

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Are you an ERS or Inflatable Office customer? Yes No

Business name:

Contact First Name:

Contact Last Name:

Phone number:

Email address:

Website:

Date of Birth:

FEIN/SS#:

Year Business Started:

Do you ever process payment cards? Yes No

Estimated annual number of payment card transactions:

Mailing Address

Mailing address:

City:

State:

Zip code:

Desired Effective Date:

Create Password (this will allow you to access you application at a later time) :

Submit