10 New King Street
Suite 210
White Plains, NY 10604
Phone: 914-686-3888
Fax: 914-686-3983
 

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Legal Name
D/B/A Name
Mailing Address
Location (if different)
Nature of Business
Telephone

Contact Name
Type of Business
Federal ID #
U.I. #
Effective Date
EE Contrib?
Carrier

Number of Employees

Males
Females
Total

Annual Payroll (max $340/week)

Additional Insureds (include FEIN for each):

1
2
3
4

Additional Locations:

1
2
3
4

Remarks