Personal/Company Data
Last Name
First
DBA/Company Name
Address
City
State
New York
Zip Code
Phone
Fax (optional)
You may contact me at the above number to
discuss this quote
E-Mail (Required)
Currently Insured
Business
Select One
Retail
Wholesale
Office
Other
Other
Yrs in business
Business Type
Claims & Amounts Paid
(If none, type None)
Describe Business In Detail
(Computer repair, Computer store, etc)
UnderWriting Information
Describe In Detail Your Business Operations
Ownership & Payroll Data
Employee's Annual Payroll (If none enter 0)
$
# of employees
Location & Sales Information
Annual Gross Revenues (If none enter 0)
$
Sq. ftge. of office or building being used
Building Type
Select One
Wood
Frame
Concrete
Other (Explain below>
Stories
Select One
One
Two
1.5
Three
Other (Explain below)
Are there other businesses/residences in this building? Yes
No
(Explain below)
Describe safety features (alarm, sprinklers, fire protection, etc.)
Remarks
Please explain all other data in the space below and
Coverage Desired
(Please select one)
Liability
Liability & Business
Liability, Business & Contents
A Package Policy
including the above plus
NOTE: Don't worry if you are not sure about coverage type. We will
suggest the best coverage for you. Tell us what you are looking
for. If additional information is needed we will contact you.
Liability Coverage
($300,000, $500,000, $1 Million, etc) $
Business Contents Coverage
(Amount of business property)
$
Building Coverage
(Amount of building coverage if owned)
$
Miscellaneous Coverage
(List any special coverage peculiar to your business, such as
Garagekeepers Legal, Loss of Earnings, Valuable Papers, etc)
$
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