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Business Owners / Commercial Package


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Insured's Name & Address
First Name
Required
Last Name
Required
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
Cell Phone Number
Optional
E-Mail Address
Required
Fax #
Optional
Contact Name
Required
FEIN
Optional
Business Status
Required




Do you own or rent this location?
Required

Business Description of all Operations
Required
Date Business was Established
Required
/ /
Number of Years experience in this Field
Optional
Physical / Garaging Address(es) of all Locations
Required
Gross Annual Sales
Required
Full Name, Percentage of Ownership, and Annual Payroll / Draw of Each Owner
Required
Value of all contents
Required
Number of full time employees
Required
Number of part time employees
Required
Gross Annual Payroll (Include Owners)
Required
Are any sub-contractors being used?
Required

If yes, what is the percentage?
Required
If yes, do you obtain certificates of insurance?
Required
Do you require additional insured/certificate holder to be added?
Required

If yes, list name and address
Required
Please list all other tenants that occupy this location (estimate)
Optional
Total square footage of building
Required
Total square footage of area being occupied
Required
Age of Building
Required
Most recent year building renovations were completed (Estimate within past 25 years i.e. Roof, Heat, Plumbing, Electric)
Required
Number of Stories
Required
Number of Basements
Required
Value of building (answer only if you own it)
Required
Type of construction building is made out of (Check all that apply)
Frame
Optional
Joisted Masonry
Optional
Non-combustible
Optional
Masonry/Non-Combustible
Optional
Fire Resistive
Optional
Modified Fire Resistive
Optional
Central Station Burgler / Fire Alarm
Optional
Sprinkler System
Optional
What percentage of the building is covered with sprinklers?
Optional
Smoke Detectors
Optional


Submission Validation
Required
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages.  Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company.  If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
 
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  575 Milltown Road | North Brunswick, NJ 08092
PH: (732) 253-8181
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