Name of Business
Type of Business
Physical Street Address, City, State and Zip Code
Web address. If you do not have a website, state NONE:
Years in business under similiar name?
Do you currently have insurance for your business?
Type of business formation
Please describe in detail about the location you are seeking coverage for. (example-office space in a 8 floor commercial office complex, office space in the basement of my primary residence, office space in a stand alone building of which I am the only business, etc)
Regarding your building location(s), are you the:
If yes, please provide the details of your current coverage. Please provide the name of the carrier, type of coverage, limits, deductibles, expiring premium and renewal date. If none, state NONE.
Regarding Property Insurance, how much in limits for the Building are you seeking?
How much insurance are you requesting to cover your equipment? If none, state NONE.
What is the usable square footage of your business?
What percentage of the premises does this business occupy?
What year was the building built?
Construction type of the building:
# of stores, not including basement
Basement (Not finished)
Basement (Partially finished)
Basement (Fully finished)
Closed with crawl space
Open – Height more than 2 feet
Open – Height less than 2 feet
What material is the roof made of?
Primary Heating Method:
Furnace (Gase or Electric)
Above ground tank
Below ground tank
How much Personal Property limits are you seeking? (including business alterations)
How high of a deductible are you willing to accept for Property Insurance?
Is there a boiler on your premises?
Do you have a smoke alarm in the building?
What type of smoke alarm?
Linked to the fire department
What type of fire protection is on the premises?
Do you have a burglar alarm in the building?
Please advise the most recent year updates were made to the following:
Do you use high power lighting for Photo or Video work?
Do you use any toxic or flammable materials in your business?
Is the computer equipment protected by fire protection & suppression device?
How often do you back up all computer data?
No backup necessary
Is back up stored off premises?
If yes, provide details. If this does not apply, state N/A.
Is computer equipment & media located above ground level?
Please state the annual gross billings for the most recent 12 month period:
How many employees do you employ?
What is your gross annual payroll?
Please provide a breakdown of your annual payroll by department. (i.e.: office, salespeople, laborers, drivers, etc.)
Do you have any operations other than the business operations described?
If so, please describe below:
Do you have any other additional locations?
If yes, please provide the location address, Building Limits and Personal Property Limits:
Would you like the vehicles used in your business to be covered under the same policy, if possible?
If yes, please provide the following information:
VIN# (17 digits)
Please provide the following driver information:
Date of Birth:
Have you have any claims the last 5 years?
If yes, please provide details and how much money was incurred by the carrier:
Would you like a quote for Umbrella Insurance?
If yes, how high of a limit in excess of the primary insurance limit are you seeking?
more than $5,000,000 excess of the primary insurance
Would you like a quick quote for Employment Practices Liability?
Did we miss something? Additional Comments:
Please utilize the “Send” Button to send your form to our office. If the website does not allow you to submit the form, please print the page and fax it to 732.334.0405 or scan it into your computer and send it to email@example.com. Do not “Refresh” the page because all data entered onto the form will be lost.
Your First Name (required)
Your Last Name (required)
Your Email (required)
Re-Enter Your Email (required)
Name Of Your Company or type of business if seeking commercial insurance (required)
Street Address (required)
Zip Code (required)