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Business information

Business name *

Address

Years in business

Legal entity

C CorporationLLCOtherPartnershipSole proprietorshipS Corporation

Annual revenue

$100,000 - $500,000$1,000,000 - $5,000,000$500,000 - $1,000,000$5,000,000 - $10,000,000Over $10,000,000Under $100,000

# of owners/partners

# of full-time employees

# of part-time employees

# of sub-contractors

Description of operations

Annual payroll

$

Do you currently have coverage?

• No
• Yes

Contact information

Your name *

Phone number *

Email *

Title

Property and casualty insurance

General liability

Commercial auto

Commercial property

Professional liability (E&O)

Directors and officers liability

Business owners package policy (BOP)

Workers compensation

Commercial crime

Employee benefits

Group health insurance

Group life insurance

Group disability insurance

401K / retirement plans

Supplemental plans / AFLAC

Key man life insurance

Key man disability insurance

Deferred compensation

Comments

Comments

Binding Agreement

I understand that for my protection, coverage cannot be bound, changed or confirmed via this online request, and that I must speak directly with a licensed representative of Insurance Network of Louisiana.

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