Life Insurance NY

CALL (516) 439-4144 FOR MORE INFO

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COMMERCIAL INSURANCE

General Liabilities Insurance

Commercial Auto Insurance

Workers Compensation Insurance

Disability Insurance

Group Insurance

Inland Marine Insurance

Bonds

Demolition Insurance

Contractors Insurance

Garage Insurance

Insurance for
Food Services

PERSONAL INSURANCE

Long Term Care Insurance

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First Hand Guide to Insurance

We are licensed in these states: NY, NJ, PA, NH, CT, and MA.
We have been very success in writing policies for the following businesses: Electricians ~ Plumbers ~ Landscapers ~ Construction ~ Deli ~ Printers ~ Garage / Auto Mechanics ~ Distributors ~ Computer Stores
Applicant Information - GENERAL INFORMATION
Your Line of Business
First Name*
Last Name *
Company Name *
Mailing Address (First Named Insured): *
City*
State*	Zip*
FEIN or Soc Sec # (of First Named Insured):*
Phone *
E-Mail Address *
Fax
Company Information
Select One * Individual Partnership Corporation Joint Venture Subchapter “S” Not For Profit Org LLC # of Members
Years in Business
Proposed Effective Date

POLICIES REQUIRED

AUTO
Limits of Liability:

DRIVER INFORMATION #1
Name:		Birthdate:
Sex:		# Years U.S. Auto License:
Number & Type of Accidents within last 3 years:
Does Driver need an SR22 FILING?	Yes No	Comments / Remarks?
COMMERCIAL VEHICLE #1:
Year of vehicle:		Make & Model:
Type of truck		Weight
Radius of operation:		Value $:
Comprehensive & Collision:
List Special Equipment & Values (i.e., rack, tool box, etc.)

COMMERCIAL GENERAL LIABILITY

Coverages | Limits

Liability

Underwriting questions

Annual Sales*

Payroll for Employees*

Payroll for Officers*

# of Officers*

# of Employees in Field*

How Many Additional Insured

Prior Carrier Information

Carrier

Policy Number

Policy Type

Occurrence

Estimated Premium Paid

Any Policy or Coverage Declined Cancelled or Non-Renewed During the Prior 3 Years? (Not Applicable in MO)

Please select one
Yes No

Loss History

Enter all claims or losses regardless of fault or not in the past 5 years

If no claims please check box:

No claims in the last 5 yearss

Workers Compensation

PAYROLL CLASSIFICATION 1

Categories, Duties

# Employees Full time

Part Time

Estimated Annual Pay Roll

PAYROLL CLASSIFICATION 2

Categories, Duties
# Employees Full time		Part Time
Estimated Annual Pay Roll

PAYROLL CLASSIFICATION 3

Categories, Duties
# Employees Full time		Part Time
Estimated Annual Pay Roll

Officer (1) to be Included/Excluded
Name
Title
Duties
Included/Excluded
Class Code
Payroll

COMING SOON
Equipment Floater (coming soon)
Garage and Dealers (coming soon)
Installation/Builders Risk (coming soon)
Professional Liability (coming soon)
Umbrella (coming soon)

I/We hereby authorize any credit bureau or any other investigative agency to investigate the references herein listed or statements or other data obtained from me / us or from any other person pertaining to my / our credit and financial responsibility.

I / We represent, warrant and affirm that all of the statements made by me / us in this application are true and correct.

Fair Credit Reporting Act disclosure: This application is for insurance purpose only and can be submitted to various Insurance companies for the purpose obtaining insurance policy (policies).

Comments/ Questions

* By checking this box - you are agreeing to the information above. This will serve as an electronic signature.

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COMMERCIAL GENERAL LIABILITY

PROPERTY SECTION Premises Information

Workers Compensation

PROPERTY SECTION
Premises Information