| Personal Information |
| First Name
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| Last Name
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| Number of Owners
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| Name(s) of Company Owner(s), with % ownership
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| Description of Operations:
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| Formal Name of Business
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| Business Type
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| Street
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| City
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| State
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| ZIP / Postal Code
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| Primary Phone Number
Required
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| E-Mail Address
Required
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| Website Address:
Required
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| Provide the person to contact for audit purposes, include name, address number and email address.
Required
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| Year Established
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| Has any entity proposed for insurance closed, sold, merged with or acquired any company in the past 12 months or anticipates doing so in the next 12 months?
Required
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| Advise if the owner(s) of this company owns another company, if so, provide details on other company and ownership % in other company.
Required
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| Provide the Federal Tax ID# of the business.
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| Provide the State Tax ID# of the business.
Required
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| Do you perform services in the State of New York?
Required
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| If “Yes,” what percentage is performed in the five (5) boroughs and what percent in the rest of New York?
Optional
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| Please list all States in which you operate.
Required
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| Estimated Annual Gross Revenue
Required
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| Prior 12 months annual gross revenue
Required
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| Advise if the owners of this company want coverage as well. If yes, advise job duties for each owner and approximate annual payroll for each owner.
Required
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| Number of full-time employees
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| Number of part-time employees
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| Number of temporary/ seasonal employees
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| Number of independent contractors
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| By category, provide estimated annual payroll paid to: owners, employees, temporary/seasonal and independent contractors.
Required
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| Do you use subcontractors?
Required
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| When hiring subcontractors, check off all that apply:
Required
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Hold down the Ctrl Key to make multiple selections. |
| What percentage of your work includes the subcontracting of work to others?
Required
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| Annual Cost of Subcontractors
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| Are subconsultants and subcontractors hired under a written, standard subcontract?
Required
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| Advise if this company has ever had a Workers Compensation policy, provide details.
Required
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| Does this company has a current Workers Compensation Insurance policy?.
Required
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| Effective Date
Optional
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| Current Policy End Date
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| Current Limits
Required
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| Current Deductible
Required
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| Current Premium
Required
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| Does the firm currently have General Liability Insurance in place?
Required
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| If yes, please provide name of General Liability insurer and approximate expiration date:
Required
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| Advise how disbursements to employees or independent contractors will be tracked. (check register, spreadsheet, etc)
Required
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| If you are not tracking these disbursements, advise the name of the company, their address and telephone number. (CPA, payroll co, etc.)
Required
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| Advise if this company has ever filed a Workers Compensation claim, provide details.
Required
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| Advise if this company has ever had an unpaid or unresolved Workers Compensation audit, provide details.
Required
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| Additional Comments
Optional
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Submission Validation Required |
Enter the Validation Code from above.
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