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Virginia Water Well Association Insurance Questionnaire

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Home » Virginia Water Well Association Insurance Questionnaire

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Please complete the below questions to the best of your ability. If a question does not apply or you do not know the answer, please skip for now.

Your Name*
First Last
Phone*
Email*
Business Name*
Annual Payroll (Drillers) or Annual Gross Sales (Retail)
Total Equipment Value (ex. Drilling Rigs, Excavators, etc.)
Number of Light Vehicles in Fleet (ex. F-150)
Number of Heavy Vehicles in Fleet
Workers’ Compensation Experience Mod Factor
Total # of Employees and # of Employees participating in Health Plan
Health Insurance Annual Premium
Current Health Insurance Provider
Coverage will not be bound or changed until confirmed by a licensed agent.
This field is for validation purposes and should be left unchanged.
This field is for validation purposes and should be left unchanged.

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