Location and Applicant Information - TULIP Application

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TULIP (Tenant User Liability Insurance Program) Application

Madison Street Plaza

, Decatur, IN 46733

Location and Applicant Information (Step 1 of 4)

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Fields marked with an asterisk (*) are required.

Applicant/Name of Group:

Applicant Name:

Type of Operation

Corporation

Individual / Sole Proprietor

Partnership / Joint Venture

Limited Liability Company (LLC)

Other

Are you operating under a Doing Business As (DBA) name?

* Yes No

DBA Name:

Other Type:

Applicant E-mail Address:

Confirm E-mail Address:

Mailing Address #1:

Mailing Address #2:

City:

State:

Zip Code:

Contact Name:

Contact Phone Number:

Extension:

Fax Number:

For Questions: STAR Insurance Agency
260-724-3111
carla.guereca@starfinancial.com