Business type:
 Business type:
631ContractorsInsurance.com
Business Insurance Quote Fax Form
Please fill print and fill out this form and
fax to 866-542-6687 ext 467
Your Personal / Company Data:

Your Name: ________________________________
Your Company's Name: ________________________________
Street Address: ________________________________
City: ________________________________
State: New York
Zip/Postal: _______________
E-Mail (REQUIRED): ________________________________
E-Mail Again (for accuracy): ________________________________
Phone: ________________________________
Fax (optional): ________________________________
 

Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type NONE) 		__________________________________
 
List Claims & Amounts Paid
(If none, type NONE) 		__________________________________
 
Years In Business: _____________________________
 
(proprietorship, corporation, etc.) /td>
 

 
 
Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type NONE) 		__________________________________
 
List Claims & Amounts Paid
(If none, type NONE) 		__________________________________
 
Years In Business: _____________________________
 
Business Type (proprietorship, corporation, etc.)
 

 
Underwriting Information:
 
Describe IN DETAIL,
Your Business Operations:		 _________________________________
______________________________________________________________________________________________
Ownership & Payroll Data:
List Employee's Annual Payroll Here (if none, enter $0): $_________ Insert # of
Employees here: 		__________________
 
Location & Sales Information:
Insert Annual Gross Revenues from this operation here: $________ Square Footage of office or business location: ___________________
 
Type of Building (wood frame, concrete, etc.): _________ Number of Stories: __________________
 
Are there other business/residences in this building (describe)?: _________ Describe safety features (alarm, sprinklers, fire protection, etc): __________________
 
Coverage Desired: (Check One Please)
The Coverage I Am Looking For:

Liability Only
Liability & Business Contents
Liability, Building & Contents Coverage
A Package Policy Including the Above,
        Plus Miscellaneous Coverages

NOTE: Don't worry if you are not exactly sure about coverage type... we will suggest the best coverage for you - just try to tell us what you are looking for! (If we need more info. we will let you know.)
 
Liability Coverage:
($300,000, $500,000, $1 Million, etc.) 		$_______________________
 
Business Contents Coverage:
(The amount of your personal business property) 		$______________________
 
Building Coverage:
(The amount of building coverage if you own your bldg.) 		$______________________
 
Miscellaneous Coverage:
(List any special coverage peculiar to your business, such as Computer Coverage, Loss of Earnings, Valuable Papers, etc.) 		_______________________
 
 
Send my quotation via: E-Mail Fax
Regular Mail
Please Call by Phone!

 
Thank you for filling out this form !

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me a
Business Owner's Quote NOW!