Home
Commercial Lines
Personal Lines
Employee Benefits
Forms
Customer Service
Business Opportunities
Feedback
Links

Contact us

Post Office:
464 Bay Ridge Avenue
Brooklyn, NY 11220-5996

For more information

Telephone:
(718) 836-1100 Local NYC
(800) 253-1490 Toll Free

Fax:
(718) 833-1582

linkogo.gif

Commercial Insurance
Applicant Information
*Name:
*Address:
 
*Phone:
Fax:
*Contact:
 
Fed ID:
Proposed Eff Date:  MM/DD/YYYY
# Years in Business:
Nature of Business:

Property Section
# of Stories:      Construction:      Year built:
Occupancies of Building:
Building: $     Deductible: $
Business Income: $
Personal Property: $     Deductible: $
Other Coverages:

Liability Section
Limit of Liability: $ Each Occurrence  
$ Aggregate  
Gross Annual Sales: $     Square Footage:     # Apts:
Annual Payroll:      # of Employees:

History
Previous Carrier:
Loss History for last 3 years :
 
* Required fields