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CONTACT INFORMATION

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FIRST NAME

MIDDLE NAME

LAST NAME

STATE

BUSINESS PHONE

BUSINESS FAX

E-MAIL

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INSURER'S NAME

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WITH THAT INSURER FOR

ESTIMATED YEARLY PREMIUM (IN US$)

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COMPANY NAME

INDUSTRY CATEGORY

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BUSINESS DESCRIPTION (NO LESS THAN 10 WORDS)

FORM OF BUSINESS

STATE BUSINESS LOCATED

YEARS IN BUSINESS

YEARS EXPERIENCE IN INDUSTRY

ANNUAL GROSS SALES (LAST 12 MO.)

ESTIMATED GROSS SALES (NEXT 12 MO.)

NUMBER OF LOCATIONS

TOTAL NUMBER OF OWNERS, OFFICERS & DIRECTORS

TOTAL NUMBER OF EMPLOYEES

ANNUAL GROSS PAYROLL (US$ EXCLUDING OWNERS, OFFICERS & DIRECTOS)

NUMBER OF FULL-TIME EMPLOYEES

NUMBER OF PART-TIME EMPLOYEES

PLEASE INDICATE TYPES OF INSURANCE YOU ARE INTERESTED IN

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Great Northern Insurance Agency Our Dedication Ensures Your Satisfaction

Commercial Quote

Our process is transparent

Products

Services

Locations

Products

Services

Locations

Great Northern Insurance © All Rights Reserved.

Great Northern Insurance Agency
Our Dedication Ensures Your Satisfaction