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?
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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) *
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Any insurance claims in the past year? *
Explain those claims in detail
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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
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Insurance information

Type of coverage
 Amount of coverage requested
Property
Wind
Flood
General Liability
Professional Liability
Workers' Compensation
Commercial Auto
Umbrella
Other
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Internal use only

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