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Workers Compensation Indication

Agency Name: Phone:
Name Insured: Email:
Description Operations:
Street Address:
City/State/Zip State: Zip:
Prior Carrier:
Lapse in Coverage: Y N If so, how many years prior?
No Of Employees: Fed TAX ID:
Class Codes: Payroll:


CL@kinginsuranceca.com - (800) 488-4096 Fax (949) 488-2259