FORMS

Auto Insurance

Life Insurance

Health Insurance

Business Insurance

Homeowner's Insurance

Professional Liability

Financial Services

Business Owner Application

Coverage Effective Date Please indicate the coverage effective date

Business Name Please indicate your business' name

Mailing Address Please indicate complete mailing address

Location Address PLease indicate complete location address

Contact Name Please indicate complete contact name

Phone Number Please indicate phone number

Age of Building Please indicate the age of the building

Description of Operation Please describe the business' operations

Construction of Building Please describe the construction of the building

Sprinklered? Please indicate if sprinklered or not

Years in Business Please indicate the number of years in business

Building Coverage Please indicate the building coverage

Deductible Please indicate deductible

Contents Coverage Please indicate contents coverage

Deductible Please indicate deductible

Computer Coverage Please indicate computer coverage

Deductible Please indicate deductible

Sign Coverage Please indicate sign coverage

Glass Coverage Please indicate glass coverage

Lenght

Width

Limit of Liability Please indicate limit of liability

Umbrella?

Prior Carrier and Policy Number Please indicate prior carrier and policy number

Prior Losses Please describe prior losses

Dates

Sales Receipts Prior Year Please indicate sales receipts for prior year

Workers Compensation Coverage Annual Payroll - (By Class) Please indicate workers compensation coverage annual payroll by class)

Prior Carrier and Policy Number Please indicate prior carrier and policy number

Prior Losses Please describe prior losses

Dates

If Corporation, Does Executive Officer Desire Coverage? If corporation, please indicate if executive officer desire coverage

Additional Comments Please include any additional comments

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Serving the following towns of the Northshore and Southshore of Long Island:

Nassau County -Baldwin, Garden City, Levittown, Valley Stream, Manhasset, New Hyde Park, Port Washington, Cold Spring Harbor, Glen Cove, Great Neck, Lloyd Harbor, Muttontown, Hicksville, Oyster Bay, Old Brookville, Roslyn, Massapequa, Wantagh, Bethpage, Seaford, Syosset, Woodbury and the surrounding areas.

Suffolk County - Babylon, Lindenhurst, Bayshore, Bohemia, Hauppauge, Melville, Shirley, Mastic, West Islip, East Islip, Oakdale, Sayville, Bayport, Huntington, Northport, Stonybrook, Kings Point, Smithtown, Saint James, Port Jefferson, Setauket, Mount Sinai, Miller Place, Center Moriches, Selden, Holbrook, Ronkonkoma, Medford and the surrounding areas.

Also serving the Five Boroughs and Tri State Area.

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