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If you have any questions call us at 800.257.7718 for help or fax at 408.997.7890 Complete Details of the Fields with * are Required Contact Information Contact Name: * (first) (last) Job Title: Tax ID/SSN: Email Address: * Telephone: * Cell Phone: Fax: Best Way to Contact: Work Phone Cell Email Best Time to Contact: Morning Afternoon Evening Company Details Company Name: * Company Address: * (street) (city) ---Select a state--- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming (zip) Mailing Address if different: (street) (city) ---Select a state--- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   (zip) How long have you been in Business under this name: New 1 2 3 4 5+ Describe type of Business, please be specific: (must exceed 10 words) * Business Entity: -----Entity Type----- Corporation Individual Joint Venture LLC (Limited Liability Company) LLP (Limited Liability Partnership) Non-Profit Partnership Trust Other Proprietorship Business Industry: -----Industry----- Accountants/Bookkeepers Advertising Agencies Air Conditiong Contractors Airboat Related Alarms/Guards Apartments Appliance Installation Appliance Repair Appliance Stores Architects/Engineers Architects/Engineers Architects/Engineers Architects/Engineers Automobile Dealerships Automobile Parts Bars Bath Shops Beauty Supplies Books/Magazines Retail Cabinet Building & Installation Cable Installation Cameras & Supplies Candy & Other Confec. Prod. Mfg. Candy/Nut & Confectionery Stores Canned Specialties Mfg. Carpentry Carpet Laying Installation Carpet Retail Ceramic Tile Installation Chiropractors' Offices Chiropractors' Offices Chiropractors' Offices Churches & Synagogues Clocks Coastal Property Commercial Fence Contractor Computer Consultants Computer Consultants Computer Consultants Computer Equipment Mfg. Consultants Consultants Consultants Dance Clubs Day Care Dental Labs Doctors/Dentists/Medical Offices Doctors/Dentists/Medical Offices Doctors/Dentists/Medical Offices Dog Grooming Shops Dog Grooming Shops Dog Grooming Shops Drug Stores Dry Cleaners Drywall Installation Contractors Electrical Supplies Electrical Wiring Contractors Electronics Mfg. Floor Covering Installation Florists/Garden Shops Food Products Mfg. Frame Contractors Funeral Directors General Contractor General Offices General Offices General Offices Gift/Souvenir Shops Glass/Glazing Work Contractor Graphic Designer Offices Graphic Designer Offices Graphic Designer Offices Greeting Cards Habitat Hardware Stores Health Food Stores Hearing Aids Heating Contractors Hobby Shops & Model Stores Horse Related Household Audio & Video Equip. Mfg. Ice Cream Parlors Import/Export Inspection & Appraisal Services Inspection & Appraisal Services Inspection & Appraisal Services Interior Designers/Decorators Interior Designers/Decorators Interior Designers/Decorators Janitorial Services Landscaping Law Offices Law Offices Law Offices Locksmiths Management Consultants Management Consultants Management Consultants Manufacturers' Representatives Marine Masonry Contractor Metal Mfg. Metal Working Job Shops Microbreweries Mfg. Musical Instrument Repair Non-Profit Organization Nursing Homes Office and Store Fixtures Office Machine Repair Office Machines Mfg. Oil & Gas Optical Goods Other Other Contracting-based Industry Other Manufacturing-based Industry Other Office-based Industry Other Retail/Wholesale Industry Other Service-based Industry Painting/Wallpapering Parks Partition and Shelves Mfg. Pet Shops & Pet Supplies Photocopying & Blueprinting Photoengraving Photographic Studios Picture Frames Plastics Machines Mfg. Plumbing Contractor Plumbing Supplies Pool Maintenance Printing (Commercial) Printing (Instant Print & Duplic.) Publishing Offices Radio & TV (Retail & Repair) Radio and TV Comm. Equip. Mfg. Real Estate Agents Rehabilitative Services Residential Contractor Restaurant Roofers Shoe Repair Shoes Software Designer Services Sporting Goods T-shirt Shops Tailors Taxidermists Telephone Equipment Installation Tobacco Tool and Die Patterns and Mold Mfg. Tour Services Tow Trucks Toys Travel Agents Tree Services Trophies Trucking Veterinarians Video Tape Stores Water Related Total Number of Employees: * 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50+ Total Annual Projected Payroll: * Current Insurance Information Name of Current Broker: Group Medical * ---Select current carrier--- AETNAAmeridentAmeritasAMOCOAWLBest PlansBlue CrossBlue ShieldCalifornia ChoiceCNACombined Insurance Co.Delta DentalFarmers InsuranceGreat WestGuardianHealth NetHIPC*Home LifeJohn AldenKaiserLife GuardLincoln NationalMetLifeNew York LifeNot InsuredOtherPacific CarePenn MutualPrincipal MutualProvidentPrudentialState FarmSuperior AccessUnum    ---Select renewal month--- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Worker's Comp * ---Select current carrier--- AlliedCCBSureFarmers InsuranceGray StoneHull & Co.Not InsuredOtherState FundSterling SpecialtySuperior AccessVia Comp    ---Select renewal month--- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Group Dental ---Select current carrier--- AETNANot InsuredOtherSuperior Access    ---Select renewal month--- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec General Liability * ---Select current carrier--- AETNACCBSureFarmers InsuranceGray StoneHull & Co.Not InsuredOtherSterling SpecialtySuperior Access    ---Select renewal month--- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Professional Liability / E & O ---Select current carrier--- CCBSureFarmers InsuranceGray StoneHull & Co.Not InsuredOtherSterling SpecialtySuperior Access    ---Select renewal month--- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Other Details Need Quote By:   What is of greatest concern to you: Premium: Extremely importantVery importantImportantNot of concern Benefits: Extremely importantVery importantImportantNot of concern Carrier Strength: Extremely importantVery importantImportantNot of concern Which option describes your company as best projected over the next 12 months: We will grow substantiallyWe will remain about the same sizeWe will downsize How did you find us: Yahoo Google Friend Previous Client Insurance Agent Other Comments/Concerns/Others: Home  |  About Us  |  Who We Are  |  Contact  |  Sign In |      Copyright 2005 Jeewanjee Insurance Agency All rights reserved California Lic # 0697055 Website Maintained by: W3Eye Inc.