Qualifying Programs Form
Any questions please feel free to contact (609) 488-4888 info@leitzinsuranceagency.com
Company Name
*
Company Name / Business Entity (LLC, Corp, Etc) Personal Name is acceptable
Owner/Contact Person
*
First Name
Last Name
Owners DOB
*
-
Month
-
Day
Year
Date
Start date of business
*
-
Month
-
Day
Year
Date
Phone Number
*
Phone Number
Format: (000) 000-0000.
E-mail
*
example@example.com
How many employees do you currently have?
*
Ratio of w-2 -----1099
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
EIN NUMBER
*
If more then one owner please list other owner and percentages here
Nature of the business
*
Annual Revenue and Annual Payroll
Submit
Should be Empty: