"Your Insurance Resource Center"
 





(631) 207-5400



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(631) 207-5400

FAX US
(631) 207-5401

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Business Owners Insurance Quote

Complete the short form below and we will get back to you with your free quote


General Information

Full Name:

Business Name:

Contact Phone:

Fax:

E-Mail:

City:

State:

Zip:

Name Of Your Current Insurance Company:

How Long Have You Been Insured With That Company?

 


Property Information

Age Of Building/Year Built:

Type Of Building Construction:

Number Of Stories:

Other Occupancies:

Square Feet You Occupy:

Year Electricity Was Updated:
Is It On Circuit Breakers?:


Yes   No

Year Plumbing Was Updated:


Copper  
Galvanized  
If Other, Please Specify:

Copper Or Galvanized Plumbing?:

Year Building Was Last Re-Roofed:
Type Of Roofing Material:


Type Of Heating System In The Building:

Burglar Alarm:


Central Station Or Local Alarm?:

Name Of Alarm Company:

Is The Building Sprinklered?:

Are There Smoke Detectors?:


Business Information

Years In Business:

Projected Gross Annual Receipts:$

Projected Annual Payroll:$

Describe Your Business, Product Or Service:

 


Coverages

 

Building: $

Contents (Equipment,Inventory,Supplies,Etc...): $

Deductible:

Loss Of Income:$

Money And Securities: $

Glass Or Signs:$

General Liability Limit:

Non-Owned And Hired Automobile Liability: $

Is Liquor Liability Needed?

 


Additional Comments and Information

 

 
   

No coverage of any kind is bound or implied by submitting information via this online form

  • We will only use information provided to assist in obtaining appropriate insurance quotes and coverage.
  • We will not distribute information to other parties other than for insurance underwriting purposes.
  • By checking the box below you agree to release us from any liability should this information be accidentally viewed by others.

YES! I Agree

   

 
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"Your Insurance Resource Center"

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(631) 207-5400
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