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Risk Purchasing Group Information
*
Required field.
TaxID
Business Name
Domicile State
Doing Business As
Business Address
City
State
Zip Code
Type of Business
Mailing Address
City
State
Zip Code
Contact Person's First Name
Contact Person's Middle Name
Contact Person's Last Name
Contact Email
Contact Address
City
State
Zip Code
Insurance Information
The RPG will purchase the following class of liability insurance:
Liability Ins. Company 1
*
Liability Ins. Company 2
State of Domicile 1
*
State of Domicile 2
NAIC Code 1
*
NAIC Code 2
FEIN 1
*
FEIN 2
Purpose of the Organization:
Contact Info
Knowledgeable Persons Regarding RPG:
1st Knowledgeable Person's Name
*
2nd Knowledgeable Person's Name
Contact Address 1
*
Contact Address 2
Contact SSN 1
*
Contact SSN 2
Contact Phone 1
*
Contact Phone 2
Insurance Program Managers/Administrators:
Responsible Person for Insurance Program:
Responsible Person's Name
Address
SSN
Phone
Admin Name 1
*
Admin Name 2
Admin Address 1
*
Admin Address 2
TaxID 1
*
TaxID 2
Admin Phone 1
*
Admin Phone 2
Agent Info
Agent/Broker:
Agent Name 1
*
Agent Name 2
Agent Address 1
*
Agent Address 2
Agent SSN 1
*
Agent SSN 2
Agent State 1
*
Agent State 2
General Description of Business Activities:
Description
Name
Attest Date
Confirmation Email
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