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CALL (516) 944-7520 FOR MORE INFO


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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
Years in Business
Proposed Effective Date
POLICIES REQUIRED


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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