Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

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Benefit Programs

Select all the benefit programs you would like to have access to:

Association Health Plans

SAIF Worker's Compensation Insurance Discount

Workplace and Promotional Supplies

Legal Services

Aglink Event and Product Discounts

2022 Gross Receipts: $0-$100k $100,001-$500k $500,001-$1M $1,000,001-$2.5M $2,500,001-$5M $5,000,001 and up

Business Type: Retail Wholesale Retail & Wholesale

Do you grow, raise, or produce any commodities aside from grapes? Yes No

If you answered Yes to the question above, please list the commodities you grow, raise and/or produce.

Full Time Employees in 2022:

Maximum number of employees at any point in 2022:

Does your company provide health insurance to your employees? Yes No

Have you purchased workers comp insurance through SAIF? Yes No

Who have you purchased workers comp insurance through?

Does your company have a mod rate of less than 1.0? Yes No Not sure