Contractors Insurance for Suffolk New York

Contractors Insurance

Suffolk, Nassau & 5 Boros of Long Island New York

www.631ContractorsInsurance.com

631- 467- 6572

Fax 631- 467-5160

	General Liability Insurance
	Auto & Truck Insurance
	Disability Insurance
	Workers Comp
	Builders Risk
	Bonds

	Home Insurance
	Auto Insurance
	Umbrella Policies
	Life Insurance
	Business Insurance
	Links
	Employment Opportunities

General Liability Insurance Quote

One Simple Form - takes only 2-3 Minutes to fill out online. You can also print this form here and fax it to us at 631-467-5160 or just give us a call!
Your Name:
BUSINESS Name:
Mailing Address:
City:
State:	New York
Zip/Postal:
E-Mail (REQUIRED):
Phone:
Fax (optional):

Business Underwriting Information
Type of operation:
Describe operations in detail:
License class:
License Number:
Social Sec. or Employer ID#:

Limit of Liability Coverage Requested?	$300,000 $500,000 $1 Million

Currently Insured?	Yes No
Name of Carrier & how long insured?
Prior Claims?	Yes No
Describe claims in detail:

Years in business:
Years experience in field:
Percentage of work residential:
Percentage of work commercial:

Number of Active Owners:
Number of Employees:	0 1 2 3+
Annual Employee Payroll: $
Annual Gross Sales: $

Do you subcontract work?	Yes No
(If yes, what percentage of your work is subbed, and what kind of work?)
Do you do foundation work?	Yes No
Do you work on condos?	Yes No
Employees paid over $18/hour?	Yes No
Do you have a safety program?	Yes No

Comments/Remarks:

Send my quotation via:	E-Mail Fax Regular Mail Please Call Me!

Thank you for filling out this form

Please Note: Insurance coverage cannot be bound without a written binder from our office. 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 them 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 Quote NOW!

Click Button Below When Done

General Liability l Worker's Comp l Auto & Truck l Bonds l Disability l Builder's Risk