Dunn & Associates Insurance, Inc.
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Employee Benefits Form


General Information
Date: 
Employer:  Phone: 
Fax #: 
Address: 
City:   County:    State:    Zip: 
Contact Person:  Email: 
Type of  Business: 
Need copy of current bill and outline of coverage.


Coverages to be  quoted:  Health   Dental
Short Term Disability   Other


Census Information
Need current UCT-6 - Quarterly Tax Report
Please fax to: 386-255-3573


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Dunn & Associates Insurance, Inc.

Phone: (386) 255-2477

324 W. International Speedway Blvd.

Fax: (386) 255-3573

Daytona Beach, FL 32114-4289


Email: info@dunn-insurance.com

© Dunn & Associates Insurance, Inc.