Cossio Insurance Agency Party Equipment Rentals
Company Information
Corporate Name:
Trade Name:
Contact First Name:
Last Name:
Phone Number:
Cell Number:
Fax Number:
Email Address:
Website:
FEIN:
Date of Birth:
Mailing Address:
City:
State:
Zip code:
Business type?
Corporation
Partnership
Individual
Nonprofit
Governmental
Other
If other, please describe:
Operation type?
with operators
without operators
both
With Operators Estimated Annual Receipts:
$
Without Operators Estimated Annual Receipts:
$
Total Items Value:
$
No. of years in business?
What date would you like your insurance coverage to start:
Policy being renewed?
Yes
No
Please make sure that you have completed everything to the best of your knowledge before going to the next page.