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PO Box 126
216 Walker St.
Houlka, MS 38850
email:
ccturner@frontiernet.net
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General Business Description
My company is interested in:
Health insurance
Commercial Automobile Insurance
Life Insurance
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Workmans Comp
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Employee Census
Name
Date of Birth
Spouse's DOB
# of Children
For Groups with more than 10 employees please enter additional
employees below:
Use the following format: Name, Date of Birth, Spouses Date of Birth, # of Children;. . .
Medical Information
Please list any medical conditions of employees, spouses, or children to be insured
List any medication that employees, spouses, or children are taking