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*Contact Person:
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*Phone #:	Fax:

* Estimated yearly payrolls per class code:
	8350 - Gasoline or Oil Dealers-Inc Drivers-U:
	5193 - Oil or Gas Burner Inst&Shop&Drvs-U:
	8810 - Clerical Office Employees NOC-U:
	8809 - Executive Offices N.O.C. Etc-U:
	8742 - Salesmen-Collectors or Messanger -U:
	8006 - Grocery-Fruit-Etc Store-Retail-U:
	5536 - Heat Air Cond Duct Shop Out&Drivers:
	Other Code:	Payroll:
	Other Code:	Payroll:

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*Are you currently a member of NYOHA? Select Yes No

Experience modification (if known):

*Type of Business:	Sole Proprietor Partnership  Corporation Other
Name of Current Insurance Company:
Date Your coverage expires:

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