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ATX

FULL NAME ( FIRST NAME, LAST NAME)
ADDRESS (#, STREET NAME, CITY, STATE, ZIP CODE)
PHONE
DOB (MM/DD/YYYY)
YEARS OF EXPERIENCE
YEARS IN BUSINESS
TYPE OF WORK (INTERIOR CARPENTRY, DRYWALL, TILE, ETC) *Be specific*
HOW MANY EMPLOYEES YOU HAVE?
ANNUAN EMPLOYEE PAYROLL ($)
COVERAGE REQUESTED - $1 MILLION - $500,000, MINIMUM
DO YOU CURRENTLY HAVE WORKERS COMPENSATION INSURANCE. YES / NO
OTHER COMMENTS (IF ANY)
EMAIL
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