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Joshua J. Stephen Associates Insurance Agency
516-481-5010- NY
516-203-7168- NY Fax
954-323-4136- FL
954-323-4052- FL Fax
Please tell us about yourself and your business
Name
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Last
Email
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Phone Number
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Date of Birth
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Mailing Address
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Business Legal Name
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DBA (If Applicable)
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Business Phone Number
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Business Fax
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Business Email (If different than above)
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Date of Inception
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Physical Address (If different from above)
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Description of Business
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Company Structure
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Corporation
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Coverage Requested (Please Check all that Apply)
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General Liability
Excess (Umbrella) Liability
Commercial Auto
Worker's Comp
Disability
Other (please describe below)
Amounts of each type of coverage requested
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Help us help you. Please provide as many of the following documents as possible.
Previous Policy Declarations Pages
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Loss Runs
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Other (please specify in comment box)
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