Small Business Insurance Quotation Form

To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you.

Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

 

 
BUSINESS INFORMATION
First Name:
Last Name:
Name of Business:
E-mail address:
Daytime Phone Number:
Evening Phone Number:
Fax Number:

How would you prefer to be contacted
regarding your quote?

 Phone Fax Mail E-mail

If you would prefer to be contacted by phone,
please let us know the best time to call.

 AM PM
Address:
City:
State:
Zip code:
Years in Business:
Policy Period:
Individual
Partnership Corporation Joint Venture Other

 

LOCATION TO BE INSURED INFORMATION
Address:
City:
State:
Zip code:
Interest of premises:

Owner Owner/Lesser Service
Office Habitational

Program:

Retail Wholesale Service
Office Habitational

Description of Operations:
Mortgagee Name & Address

 

LIMITS OF INSURANCE and OPTIONAL COVERAGES
Building:
Replacement Cost: $
Actual Cash Value: $
Construction: Frame:
Jointed Masonry:
Masonry: Noncombustable:
Fire Resistive:
Sq. foot area of each building:
Sq. foot area occupied by applicant:
Year of Construction:
Number of Stories:
Business Personal Property:
Deductible:
Exterior Glass:
Sign:
Money & Securities
($10,000 Inside/$2,000 outside):
Systems Breakdown/Boiler &
Machinery
Accounts Receivable
Valuable Papers:
Business Computer: Hardware:
Software:
Employee Dishonesty:
Business Liability:
Additional Insured Name Address:
Non-owned hired automobile: Yes No
Annual sales:
Annual payroll:

 

REMARKS

 

Insurance Express
516-377-0100
Fax: 516-377-3763