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General Info 2
General Info 3
Section 1: POLICY RECOMMENDATIONS
(Please check any you are interested in)
Hired & Non-Owned Auto
1) Currently valued loss runs for the last 5 years
2) Waiver or Rental Agreement
3) Daily Safety Checklist
How did you hear about us?
Are you an ERS or Inflatable Office customer?
Contact First Name:
Contact Last Name:
Date of Birth:
Year Business Started:
Do you ever process payment cards?
Estimated annual number of payment card transactions:
Desired Effective Date:
Please make sure that you have completed everything to the best of your knowledge before going to the next page.