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    Workers Compensation Form






























    INSURED HISTORY:






























    Indicate the safety activities currently established and practiced regularly:















    HIRING PRACTICES:











    AUTOMOBILES:

    Business Operations include driving by employees for the following purpose(s):

























    PAYROLL AND PREMIUM HISTORY:














    The above information is true to the best of my knowledge. I authorize Insure Pal Insurance Services the use of the above information for the purpose of obtaining a quotation for insurance. I also understand by submitting this information does not mean that I have purchased an insurance policy. This information is used only to provide a quote.

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