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Section 1: POLICY RECOMMENDATIONS
(Please check any you are interested in)
Hired & Non-Owned Auto
Section 1B: Company Information
How did you hear about us?
Name of facility:
Contact first name:
Date of Birth:
If other, please describe:
Year business was established:
Number of years under present management:
How many years of management experience do you have?
Do you ever process payment cards?
Estimated annual number of payment card transactions:
Does the Applicant have a formal safety training program for employees?
Does the Applicant have a safety manager on premises at all times the facility is open?
If yes, please provide the name and contact information:
Desired Effective Date:
Please make sure that you have completed everything to the best of your knowledge before going to the next page.