John Galt Insurance Agency

CNR Application

Company Information

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Description of your business

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Are you a Daycare 
or Private School? *
Do you currently pay in
excess of $10,000 annually

for all of your business 
insurance combined?
Does your company currently offer Health 
Care, Life, Dental, Disability or a 401k plan
to your employees?
Do you have any
company vehicles? *
Are all scheduled vehicles 
owned by your company? *
Lein Holder(s) *
Any insurance claims in the past year? *
Explain those claims in detail

Enrollee Information

Note that this information is needed not only for the employee, but also for any of their dependents also on their coverage.

Enrollment Type - Employee only (EO), Employee + Spouse (ES), Employee + Children (EC) or Family (F)

1) First & Last Name 2) Enrollment Type (EO, ES, EC or F) 3) Home Zip Code 4) Gender (M or F) 5) DOB

Insurance information

Type of coverage
 Amount of coverage requested
General Liability
Professional Liability
Workers' Compensation
Commercial Auto

Internal use only

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