The Mark Gilliam Agency
4625 Alexander Drive
Suite 115
Alpharetta, GA 30022
Phone: (770) 777-0743
Fax: (770) 751-7333
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Full Name:
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Company Name:
Mailing Address:
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City, State, ZIP Code:
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Location Address (if different):
E-Mail:
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Home Phone:
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Secondary Phone:
Please Describe Your Business
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Business Structure:
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Individual
Partnership
Corporation
How Many Years in Business:
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Do You Have Existing Insurance:
Yes
No
Any Losses in the Last 3 Years:
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Yes
No
Please list any current carriers and how long you've been insured with them
What Type Policy Do You Need:
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General Liability
Worker's Compensation
Businessowner's
Commercial Auto
Other
Coverage Amount Desired:
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