Business Information Form Step 1 of 2 50% Business DetailsName of Person Completing Form:* First Last Phone Number:*Email:* Business Name:* Business Entity:* FEIN / Tax-ID Number: Mailing Address:* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is Physical Address Same As Mailing Address?* Yes No Physical Address:* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Company Website: Effective Date MM slash DD slash YYYY Are You A Contractor?* Yes No Brief Description of Operations:Year Business Started: Number of Employees:Estimated Annual Payroll:Estimated Annual Revenue:Please list the names of all owners and include the % of ownership for each.*Consent* I agree to the Republix privacy policy and provide my consent to be contacted.I agree to the Republix privacy policy https://www.joinrepublix.com/privacy-policy-3/ and provide consent to be contacted via email, phone call and SMS text message regarding my insurance. Additional Contractor DetailsContractors License # % of work Subcontracted out % of Residential Work % of Commercial Work % of Remodel/Install work % of New Construction Work % of Service/Maintenance Work Do you perform Government/Municipality Work?YesNo