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MASTER APPLICATION AND AGREEMENT FOR INSURANCE COVERAGEOctober 30th, 2019
Company Information Legal Name of Business: Requested Effective Date: q Corporationq Partnershipq Proprietorshipq Other dba (if applicable): Employer Tax ID Number (EIN): Type of Business: NAICS Code: Billing Address: (street, city, zip) Shipping Address: (if different) Billing Contact (q Contact for SIMON portal invitation?): Phone: Email: Eligibility Contact (q Contact for SIMON portal invitation?): Phone: Email:
