Abbey Insurance & Tax Services

First Name
Last Name
Company Name
Address Line 1
Address Line 2
City
State
Zip Code
Daytime Phone	() -
Evening Phone	() -
Fax	() -
E-mail Address
Fed Tax ID
Nature of business please decribe
Number of years in business
Individual, partnership, corporation, subchapter "s" corp
Proposed effective date
Describe duties of employees to be covered
List the number of FT employees
List the estimated annual payroll for FT employees
List the number of PT employees
List the estimated annual payroll for PT employees
List the name, date of birth, duties, and annual income for each Owner
Include or Exclude owners income and list the amount of owner income
List past three prior year insurance company name and year covered
List prior year policy number
Is a written safety program in operation
Any employees with physical handicaps
Are employee health plans provided
Any tax liens or bankruptcy within the last 5 years
Any worker's compensation claims in the past three years? If yes please list how many
Referring organization name?

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