General Liability/Workers Comp Application : Elite Insurance Louisiana

Name*

First Last

Name of Business*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Email

Phone

Address of Business (if different from mailing address)

Street Address Address Line 2 City State ZIP Code

Business Information

Business Type*

Years of Business

Years of Experience

Nature of Business (1000 characters)

Job Description (1000 characters)

Annual Sales (if no employees, please list owner payroll)

Coverage Limits Desired

Do You Use Subcontractors

What Type of Work is Subbed Out? (1000 characters)

Payroll Amount for Subs

W-2 Payroll

1099 Payroll

Any Losses?

Do You Wish To Be Excluded From The Policy

Any Additional Info You Wish To Disclose? (1000 characters)