For the fastest and most accurate insurance quote, please provide as much information possible in the form below.
This information will be kept confidential and will be used for quote purposes ONLY!
Business Information
Contact Name:
Business Name:
Email:
Website Address:
Address:
City: State: ZIP:
County:
Phone: ( ) - Fax: ( ) -
# of years in Business: _____ yrs. #of Employees: ___ Full Time _________ Part Time
Federal ID #:
Building Location / Property Information
Address:
City: State: ZIP:
Do you Own or Rent?: Own Rent
Year Building Built Is there an Alarm?: Central Local
Area Occupied:
Bldg. Square Footage: sq. ft.
Building Construction: masonry frame fire resistive
Building Limit:
Business Contents/ Personal Property Limit:
Deductible: Percent of Building Sprinklered: %
Business Operations
Please give a Description of Your Operations and What You Make/ Do Below:
Accounting Information
Annual Gross Receipts: $
Total Payroll : $
Do you do installation or repair ?: Yes If YES, estimate % of annual sales: %
Federal ID #:
Liability / Loss History / Coverages / Current Policy Info
Liability:
Have there ever been any losses?: Yes No
If YES, please give date of loss(s), description(s), and amount of loss(s).
Other coverages requested: Auto Workers' Comp. Umbrella Installation
Do you currently have
Insurance if Force?: Yes No If YES, give expiration date:
Additional Comments
Please give any additional comments about the coverage you desire:
Please press the Submit button to send this form electronically.
If you wish to print out this form and mail or fax it to,
please send to the address or fax number listed below.
This information will be kept confidential and will be used for quote purposes ONLY!
Business Information
Contact Name:
Business Name:
Email:
Website Address:
Address:
City: State: ZIP:
County:
Phone: ( ) - Fax: ( ) -
# of years in Business: _____ yrs. #of Employees: ___ Full Time _________ Part Time
Federal ID #:
Building Location / Property Information
Address:
City: State: ZIP:
Do you Own or Rent?: Own Rent
Year Building Built Is there an Alarm?: Central Local
Area Occupied:
Bldg. Square Footage: sq. ft.
Building Construction: masonry frame fire resistive
Building Limit:
Business Contents/ Personal Property Limit:
Deductible: Percent of Building Sprinklered: %
Business Operations
Please give a Description of Your Operations and What You Make/ Do Below:
Accounting Information
Annual Gross Receipts: $
Total Payroll : $
Do you do installation or repair ?: Yes If YES, estimate % of annual sales: %
Federal ID #:
Liability / Loss History / Coverages / Current Policy Info
Liability:
Have there ever been any losses?: Yes No
If YES, please give date of loss(s), description(s), and amount of loss(s).
Other coverages requested: Auto Workers' Comp. Umbrella Installation
Do you currently have
Insurance if Force?: Yes No If YES, give expiration date:
Additional Comments
Please give any additional comments about the coverage you desire:
Please press the Submit button to send this form electronically.
If you wish to print out this form and mail or fax it to,
please send to the address or fax number listed below.
Email or fax this page to 631 422 8586 - Classic Coverage Insurance
Classic
Coverage
Coverage
Call Us Toll Free
1(800)982-0098
1(800)982-0098
Insurance Agency
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