Kennedy Insurance Agency - Workers Comp

<P class=MsoNormal style="MARGIN: 0in 0in 0pt"><B style="mso-bidi-font-weight: normal"><FONT size=3><FONT face="Times New Roman">1. Named Insured:<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></FONT></FONT></B></P> <P class=MsoNormal style="MARGIN: 0in 0in 0pt"><B style="mso-bidi-font-weight: normal"><FONT size=3><FONT face="Times New Roman">2. D.B.A.:<o:p></o:p></FONT></FONT></B></P> <P class=MsoNormal style="MARGIN: 0in 0in 0pt"><B style="mso-bidi-font-weight: normal"><FONT size=3><FONT face="Times New Roman">3. Business Operations:<o:p></o:p></FONT></FONT></B></P> <P class=MsoNormal style="MARGIN: 0in 0in 0pt"><B style="mso-bidi-font-weight: normal"><FONT size=3><FONT face="Times New Roman">4. Number of Years in Business:<o:p></o:p></FONT></FONT></B></P> <P class=MsoNormal style="MARGIN: 0in 0in 0pt"><B style="mso-bidi-font-weight: normal"><FONT size=3><FONT face="Times New Roman">5. Mailing Address:<o:p></o:p></FONT></FONT></B></P> <P class=MsoNormal style="MARGIN: 0in 0in 0pt"><B style="mso-bidi-font-weight: normal"><FONT size=3><FONT face="Times New Roman">6. Physical Address:<o:p></o:p></FONT></FONT></B></P> <P class=MsoNormal style="MARGIN: 0in 0in 0pt"><B style="mso-bidi-font-weight: normal"><FONT size=3><FONT face="Times New Roman">7. Business Entity: (Please Choose One)<o:p></o:p></FONT></FONT></B></P> <P class=MsoNormal style="MARGIN: 0in 0in 0pt"><B style="mso-bidi-font-weight: normal"><FONT size=3><FONT face="Times New Roman">8. Federal Employer Identification Number:<o:p></o:p></FONT></FONT></B></P> <P class=MsoNormal style="MARGIN: 0in 0in 0pt"><B style="mso-bidi-font-weight: normal"><FONT size=3><FONT face="Times New Roman">9. States Where Work Is Performed:<o:p></o:p></FONT></FONT></B></P> <P class=MsoNormal style="MARGIN: 0in 0in 0pt"><B style="mso-bidi-font-weight: normal"><FONT size=3><FONT face="Times New Roman">10. Health Insurance Provided:<o:p></o:p></FONT></FONT></B></P> <P class=MsoNormal style="MARGIN: 0in 0in 0pt"><B style="mso-bidi-font-weight: normal"><FONT size=3><FONT face="Times New Roman">11. If Yes, Name of Health Insurance Provider:<o:p></o:p></FONT></FONT></B></P> <P class=MsoNormal style="MARGIN: 0in 0in 0pt"><B style="mso-bidi-font-weight: normal"><FONT size=3><FONT face="Times New Roman">12. Health Insurance Anniversary Date:<o:p></o:p></FONT></FONT></B></P> <P class=MsoNormal style="MARGIN: 0in 0in 0pt"><B style="mso-bidi-font-weight: normal"><FONT size=3><FONT face="Times New Roman">(If Applicable)<o:p></o:p></FONT></FONT></B></P> <P class=MsoNormal style="MARGIN: 0in 0in 0pt"><B style="mso-bidi-font-weight: normal"><FONT size=3><FONT face="Times New Roman">13. Any Vehicle Exposure:<o:p></o:p></FONT></FONT></B></P> <P class=MsoNormal style="MARGIN: 0in 0in 0pt"><B style="mso-bidi-font-weight: normal"><FONT size=3><FONT face="Times New Roman">14. Hours of Operation:<o:p></o:p></FONT></FONT></B></P> <P class=MsoNormal style="MARGIN: 0in 0in 0pt"><B style="mso-bidi-font-weight: normal"><FONT size=3><FONT face="Times New Roman">15. Ownership Active in Management:<o:p></o:p></FONT></FONT></B></P> <P class=MsoNormal style="MARGIN: 0in 0in 0pt"><B style="mso-bidi-font-weight: normal"><FONT size=3><FONT face="Times New Roman">16. Is a Formal Safety Program in Place:<o:p></o:p></FONT></FONT></B></P>