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Business Name
*
DBA
Business Entity
Select
LLC
Corporation
Sole Proprietor
Partnership
Please Indicate if you are:
*
New in Busines
Have Prior Coverage
Cell Phone
*
Email
*
Your Website URL/Address
Indicate Number of Employees
*
Indicate Number of Active Owners
*
Are you Licensed with Oregon Bureau of Labor and Industries (BOLI)?
*
Yes
No
If Yes, BOLI License Number & Expiration Date
*
1/2
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ANNUAL PROJECTIONS
Gross Receipts
*
Payroll: (Exclude Owners)
*
Subcontractor Costs
*
Do you Subcontract?
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Yes
No
If Yes, what work do you Subcontract out?
*
PRIOR 3 YEARS OF INCOME AND SALES
Gross Receipts
*
Payroll (Exclude Owners)
*
Subconstractor Costs
*
Select All That Apply to You Operations:
*
Carpet Cleaning
Interior Window Washing
Exterior Window Washing*
Floor Waxing
Pressure Washing
Restocking Supplies
Restaurant Hood Cleaning
Auto Detailing
Building Maintenance
*If working on Exterior Windows, up to how many floors?
*
Indicate the Type of Structures, Buildings, Facilities that you work in:
*
Apartment Move In/Move Out
Office Cleaning
Schools/Daycares
Residential Cleaning
Retail/Shopping Centers
Commercial/Industrial
Hospitals/Clinics
CLAIMS
Have you had any legal claims, lawsuits or accusations against your business in the last 5 years?
*
Yes
No
Are you Interested in obtaining a quote for any of the below?
Workers Compensation
Inland Marine (Tool Coverage)
Commercial Auto
General Liability
Property
Pollution Liability
EPLI
Life Insurance
Sign and Date
*
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