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    Underwriting Information
    Company Name
    Your Name
    Email Address
    Email (for accuracy)
    Street Address
    City
    County
    State: (Must be Florida)
    Zip
    Phone (daytime)
    Ext.
    Phone (evening)
    Fax
     
    About Your Business
    Sole Proprietor Partnership Corporation LLC Association
    Do you currently have Professional Liability Owners insurance?
    Yes No
    Number of Owners or Officers?
    If "Yes", when does your current policy expire?
    If "Yes", who are you currently insured with?
    Type of Business
    Description of Business Operations:
    Do you currently have Business Liability Owners insurance?
    Yes No
    Year Business Established
    Number of Locations
    Number of Employees
    Approximate Annual Gross Revenue
    Approximate Amount of Desired Insurance
    Has your company submitted any claims in the last 3 years?
    Yes No
    If "Yes", briefly explain:
     
    Optional coverage (check the ones you may want)
    Group Health Business Property
    Business Owners Life
    Workers Compensation Group Health
    Commercial Auto/Truck Other
     
    Details

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    Florida Commercial Insurance (An Affiliate of Insurance Office of America)
    4915 West Cypress Street | Tampa, FL 33607 | Phone: 813-262-2303 | Fax: 813-637-8484
    Email: bruce.johnson@ioausa.com | Florida Insurance License #: A132126