The PRM Companies
PO Box 12305
Albany, NY 12212
(800) 958-7475
Program Name:
First Name
Last Name
Salutation
Mr.
Mrs.
Ms.
Miss
Dr.
E-mail Address
Telephone Number
Fax Number
Business Street Address
Business City
Business State
Business ZIP Code
Name of Business(es)
Type of
Business
Sole
Proprietor
Limited
Liability Company (LLC)
Partnership
Professional
Service Liability Company (PSLC)
Corporation
Registered
Limited Liability Partnership (RLLP)
Political
Subdivision
Other
-specify
Anticipated
Effective Date
Year
(required)
(must be current or future
date)
Describe your business operations, including
products or services sold
List your
estimated annual payroll by type of work or duties
Classification
Payroll (no commas please)
Number of Employees
Clerks/Bookkeepers
Outside Sales/Messengers
Corporate Officers
List and describe other classifications that may apply to
your business (include payroll and employee count)
Note: Up to two corporate officers who collectively
own 100% of the corporation's stock have the option to be
excluded from coverage.
Should any officers be excluded? Yes
No
If Yes, list
officers to be excluded:
First Exclusion:
First Name
Last Name
Second Exclusion:
First Name
Last Name
Note for Sole Proprietors and Co-Partners: If you are
self-employed or a
partner (as defined under Section 10 of the Partnership
Law), you may be
covered but the premium would be based on a remuneration of
at least $22,100 and not more than $66,300 annually through
September 30, 2000.
Does
this apply to you?
Yes
No
If Yes, please
complete the following:
Sole Proprietor:
First Name
Last Name
1st Partner:
First Name
Last Name
2nd Partner:
First Name
Last Name
Additional Partners:
Would you like a
representative to contact you? Yes
No
