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Rockdale Life Agency, Inc
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Zip Code

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Great! What is the business name?

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How many partners/owners?

Number Partners
Number Partners
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How many full-time employees?

Fulltime Employees
Fulltime Employees
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How many part-time employees?

Part-time Employees
Part-time Employees
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How many sub-contractors?

Number Contractors
Number Contractors
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What is the entity/status?

Partnership
S Corporation
C Corporation
Joint Venture
Limited Liability Corporation
Individual/Sole-Proprietorship
Municipality
Trust
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How many years in business?

0-2 Years
3-5 Years
6-10 Years
11-20 Years
20+ Years
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What is the gross annual revenue?

Less than $50,000
$50,001-$100,000
$100,001-$250,000
$250,001-$500,000
$500,001-$1,000,000
$1,000,001-$5,000,000
$5,000,001-$10,000,000
$10,000,000+
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Briefly describe your business

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How much property/casualty insurance?

(check any that apply)
    Property Insurance
    Property Insurance
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    What are the desired employee benefits?

    (check any that apply)
      Employee Benefits
      Employee Benefits
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      What is the gross annual payroll?

      Less than $50,000
      $50,001-$100,000
      $100,001-$250,000
      $250,001-$500,000
      $500,001-$1,000,000
      $1,000,001-$5,000,000
      $5,000,001-$10,000,000
      $10,000,000+
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      What is your full name?

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      What is your email address?

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      What is your phone number?

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      Georgia Resident Agent | License 189786