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Contact Information

First Name ✶

Last Name ✶

Phone ✶

Email

Title

Business Information

Location

Business Name ✶

Federal EIN (Employer Identification Number) or Business Tax ID (FEIN) ✶

How many years has your business been in operation? ✶

Enter 0 if newly started this year.

How many owners does the business have? ✶

Include yourself and any co-owners or partners.

Street Address ✶

City ✶

State ✶

ZIP ✶

General

Business Type ✶

Industry ✶

Website

Operations

Description of Operations

Annual Revenue ✶

Estimated Annual Payroll ($) ✶

Number of Employees ✶

Number of Business Vehicles ✶

Number of Drivers ✶

Coverage Information

Current Insurance Company ✶

Current Policy Expiration ✶

What types of coverage are you interested in?

Commercial Auto

Commercial Liability

Commercial Property

Commercial Umbrella

Cyber Liability

Workers Compensation

Additional Information

How did you hear about Insurance Network of Louisiana? ✶

Select how you were referred to us (or choose 'Other' to tell us more):

Comments

I understand that insurance coverage is not bound or altered until I receive confirmation by an authorized representative of Insurance Network of Louisiana ✶

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