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JULIAN D. ROACH
CEC BODY SHOP

Disability Insurance Quotation


LOGIN INFORMATION
Please Fill up the Information Required for your future Login and check the order status. If you already have the login information for Infotax then please type your existing email and password.
Email*:
Password*:
ORDER INFORMATION
Note: If you agree to the quotation and would like to apply for it additional Infotax Square fees $75.00 + annual premium for the policy (which will be paid to your insurance carrier) will be charged.
Infotax Square fees for getting quotation for Disability Insurance: $
Do you need Notification?* Yes No
Total: $
Reseller Discount: $
Total: $
CONTACT INFORMATION (This is where we will ship your documents)
First Name*:
Last Name*:
Address*:
Suite/Apt:
City*:
State*:
Zip*:  (99999) OR (99999-9999)
Phone*:
Fax:
 
BUSINESS OVERVIEW
Type of Entity*:
Name of Entity*:
DBA/Assumed Name*:
State of Formation*:
Date of Formation*:  (mm/dd/yyyy)
Employer ID Number*:
Unemployment Tax ID (if any):
  Same as Contact Information
Address:
(If different from the above)
Suite/Apt:
City:
State:
Zip:  (99999) OR (99999-9999)
County:
OFFICERS/DIRECTORS INFORMATION
OFFICER 1
  Same as Contact Information
Full Name*:
Title*:
Residence Address*:
City*:
State*:
Zip*:  (99999) OR (99999-9999)
Phone:
Fax:
Duties:
Annual Salary:
OFFICER 2 
Full Name:
Title:
Residence Address:
City:
State:
Zip:  (99999) OR (99999-9999)
Phone:
Fax:
Duties:
Annual Salary:
OFFICER 3 
Full Name:
Title:
Residence Address:
City:
State:
Zip:  (99999) OR (99999-9999)
Phone:
Fax:
Duties:
Annual Salary:
Do you want to exclude officers: Yes No
INSURANCE INFORMATION
Requested effective date of Insurance*:  (mm/dd/yyyy)
Number of Employees (Male)*:
Total Annual Salary (Male)*:
Number of Employees (Female)*:
Total Annual Salary (Female)*:
Number of Locations to be covered under Worker Compensation*:
Have you ever been insured for worker compensation Insurance*: Yes No
Name Of Insurer*:
Year*:
Policy Number*:
Annual Premium*:
Reason for Cancellation*:
Have you ever been in business under different name*: Yes No
Entity Name*:
DBA/Assumed Name (if any)*:
Employer ID Number*:
Nature of business, describe in detail:
PAYMENT INFORMATION
  Same as Contact Information
First Name*:
Last Name*:
Billing Address*:
City*:
State*:
Zip*:  (99999) OR (99999-9999)
Phone*:
Fax:
Card Type*:
Expiration Date*:
Card Number*:
Card Security Code*:
Please use the security code as follow:

1. Master Card- Please insert 3 digits security code from the back of the card
2. Visa Card- Please insert 3 digits security code from the back of the card
3. Discover Card- Please insert 3 digits security code from the back of the card
4. American Express- Please insert 4 digits security code from the front of American Express

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Country:
 
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