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TRIREME INSURANCE SERVICES, INC
WORKERS' COMPENSATION INSURANCE QUESTIONNAIRE

Tel:626-653-0708 Fax:626-653-0707

NAME OF THE COMPANY: *
MAILING ADDRESS: *
CITY: *    
STATE: * ZIP CODE: *
TEL: * FAX:
PERSON CONTACT: *
NATURE OF BUSINESS:
CORPORATION    INDIVIDUAL    OTHERS    
YEARS IN BUSINESS?
MAIN PRODUCTS
FEDERAL EMPLOYER ID


SECTION ONE : EMPLOYEE INFORMATION
JOB CLASSIFICATION NO.OF EMPLOYEES ESTIMATED ANNUAL SALARY


SECTION TWO : YOUR BUSINESS
ANY MEDICAL INSURANCE ? Y    N    
ANY PAID VACATIN & SICK LEAVE? Y    N    
PROVIDE PRODUCT ASSEMBLY? Y    N    
PROVIDE PRODUCT REPAIRING OR INSTALLING SERRVICE? Y    N    
PROVIDE DELIVERY OR PICK UP SERVICE? Y    N    
PROVIDE SAFETY TRAINNING? Y    N    


SECTION THREE : THE PRIOR INSURANCE INFORMATION
DO YOU HAVE ANY PRIOR INSURANCE ? Y    N    
PRIOR INSURANCE NAME?
EXPIRATION: ANY CLAIM OR LOST? Y    N    
DATE OF LOST:    AMOUNT PAID $
REASON OF LOST  


SECTION FOUR : DETAIL DESCRIPTION OF YOUR BUSINESS OPERATION
 
        


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