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Request a Certificate
of 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: Bakeries ~ pizzerias ~ Workers Comp ~ Electricians ~ Plumbers ~ Landscapers ~ Construction ~ Deli ~ Printers ~ Garage / Auto Mechanics ~ Distributors ~ Computer Stores ~ Business autos
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