Name: Brannon East Agency
Address: 10 Hamilton Blvd Suite F, Cartersville, GA, 30120, USA
Telephone: (770) 999-0380

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Business Name *

Years in Business *

EIN# / Employer Identification Number *

Do you or your business supply, manufacture, or distribute any tangible goods or products? *

Do you currently have an insurance policy in effect for the coverage requested? *

For the next 12 months, what is your estimated payroll expense for yourself, your full-time, part-time, and temporary employees? (Do not include subcontractors.) *

What are your business's estimated gross sales during the next 12 months? *

Does your business use a written contract or statement of work? *

Legal Entity *

Partners/Owners *

Full-Time Employees *

Will this replace an existing business policy? *

Part-time Employees *

Sub-Contractors *

Is this a one-time event or seasonal business? *

Annual Revenue *

Please describe the specific nature of your business. *

When would you like this policy to start? *

What type(s) of business insurance are you interested in?

Contact Name *

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Additional Comments? *

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