1000 Main Street, PO Box 70
Holbrook, New York 11741
Tel: 631-588-2116    Fax: 631-588-2147

   We Offer:

Business Insurance Quotation Request

Please fill in the information requested below.
When you are finished, click 'Submit'.
One of our representatives will contact you within 48 hours with a quotation. Thank you

Business Name and Mailing Address
Company Name
Contact Person
Business Mailing Address
City State Zip
Phone Fax  
Federal Tax ID No.  
Property address, if different from above  
City State Zip  
Description of Business Operation
Complete this section if you need building coverage  
Current amount of insurance  
What year was it built?  
Type of Construction  
How many stories?  
Square footage occupied?  
Approx. total building square footage?  
Is there a burglar alarm? Yes No  
Is there a fire alarm? Yes No  
Is there a smoke alarm? Yes No  
Are the alarms monitored? Yes No  
Is the building sprinklered? Yes No  
Commercial Auto - Driver Information  
Driver Name (as on License) Date of Birth NY Driver License Number
Commercial Auto - Vehicle Information  
Vehicle Year, Make, Model Vehicle ID No.
Liability Coverage  
Present liability per occurance aggregate  
How many employees? Full Time Part Time  
Annual payroll  
Annual receipts  
Umbrella/Excess Liability  
Present limit of liability  

Any questions or comments?

Please note: Filling out this form will NOT cause
an insurance policy to be issued.
I understand that the insurance companies that provide a quote may review my credit history or obtain and use a credit based insurance score based on the information contained in that report. The insurance company may use a third party in connection with the development of your insurance score.