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Legal Name/DBA:

My FEIN is:

Years In Business:

My Contact Name is:

My Contact Title is:

My Contact Email is:

My Cell Phone is:

My Office Phone is:

My Fax Phone is:

Description Of Operations:

My Full Business Address:

This is my

Group One

Employee Title:

Work Description:

Number Of Employees In This Group:

Group Two

Employee Title:

Work Description:

Number Of Employees In This Group:

Group Three

Employee Title:

Work Description:

Number Of Employees In This Group:

Group Four

Employee Title:

Work Description:

Number Of Employees In This Group:

W/C Loss History (past 3 years)

Year One

Year:	# of claims:
Total $ Incurred:	Open Or Closed:

Year Two

Year:	# of claims:
Total $ Incurred:	Open Or Closed:

Year Three

Year:	# of claims:
Total $ Incurred:	Open Or Closed:

Name Of Current Carrier Or Leasing Company:

Please know we value your privacy!

Legal Name/DBA:

My FEIN is:

Years In Business:

My Contact Name is:

My Contact Title is:

My Contact Email is:

My Cell Phone is:

My Office Phone is:

My Fax Phone is:

Description Of Operations:

My Full Business Address:

This is my

Group One

Employee Title:

Work Description:

Number Of Employees In This Group:

Group Two

Employee Title:

Work Description:

Number Of Employees In This Group:

Group Three

Employee Title:

Work Description:

Number Of Employees In This Group:

Group Four

Employee Title:

Work Description:

Number Of Employees In This Group:

W/C Loss History (past 3 years)

Year One

Year:	# of claims:
Total $ Incurred:	Open Or Closed:

Year Two

Year:	# of claims:
Total $ Incurred:	Open Or Closed:

Year Three

Year:	# of claims:
Total $ Incurred:	Open Or Closed:

Name Of Current Carrier Or Leasing Company:

CALL US

Home Page

FAQ Page

EMAIL US

Anthony F. Cannella
Your ACANN Business Consultant
Local Office:
1277 Jefferson Blvd.
Warwick, RI 02886
954-275-9322