Employers Pro Advantage :: More Then Just Payroll

GENERAL LIABILITY

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Name:
Company:
Email:
Telephone:
Fax:

Mailing Address:
City:
State:
Zip:

Physical Address: if different from mailing address
City:
State:
Zip:

Years in Business:
Business Legal Entity:

What industry is your business in?

Other:

Description of the nature of business:

Duties That Employees Perform		Estimated Annual Payroll

Estimated annual payroll (excluding owner)

Amount of Coverage needed

Number of Owners, Officers or Partners:
Owners, Officers or Partners to be included from coverage:
Owners, Officers or Partners to be excluded from coverage:


Previous or Existing Coverage: