Impact Agency Insurance Solutions

Work Comp Application Information - Auto Dealer no towing, no body shop

 

Please complete the form below

We will contact you within 24 hours. If we have further questions, we will address them at that time.

In addition to this application, we will need full 5 year loss history.

Phone *
Phone
Mailing Address *
Mailing Address
Company Legal Structure *
Proposed Effective Date *
Proposed Effective Date
Full name, DOB, title, ownership percentage and included/excluded for each person
Name of person completing application *
Name of person completing application