Padgett Insurance Agency PO Box 1119 Richmond Hill, GA 31324
11258 Ford Ave Suite 2 Richmond Hill, GA 31324
Phone: (912) 756 - 6394 Fax: (912) 756 - 2804 Email Us
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*Applicant Name:
*Legal Name of Business:
*Fed-ID-#:
*Phone:
Fax:
*Email:
*Mailing Address:
*City:
*State:
Zip:
Currently insured?
Yes
No
If yes, with what company?
Policy expiration date:
If no, reason:
*Nature of Business:
*Years in business:
*# of employees:
*Check one:
Individual
Corporation
LLC
Partnership
Subchapter S
Other
Has your insurance ever been cancelled or non-renewed? If so, for what reason:
Describe all losses within the last 3 years, whether reimbursed or not. Include date and amount of loss:
Location #
Street, city, county, state, zip code
1
2
3
4
State:
Location #:
Class code (if known):
# full-time employees:
# part-time employees:
Categories, duties, classifications:
Estimated Annual Remuneration:
Name
Title
% Ownership
Include/Exclude
include
exclude
Has any prior coverage been declined, cancelled or non-renewed in last 3 years? Explain:
Any undisputed and unpaid worker's comp premium due from you or any commonly managed or owned enterprises? Explain:
Any work performed underground or above 15 feet? Explain:
Any work performed on barges, vessels, docks, bridge over water? Explain:
Are subcontractors used? Give % of work subcontracted:
Any work sublet without certificates of insurance? Explain:
Please review your entries for accuracy before submitting your request.
