Harvey M. Goldfarb, President
about us personal commercial contractors quote request online services  

Business Liability Quote Request (back)

Fill out the form below and click the "submit" button to receive a quote from our qualified staff. You should receive a response within 1 business day of your submitting the form.

We service the following states online: New York, New Jersey, Connecticut, Massachusetts, and Florida. For all other states, please call or email us.

Contact Information
*Contact Name:
*Business Name:
*Mailing Address:
*Mailing City:
*Mailing State:
*Mailing Zip Code:
*Phone Number:
(including area code)
Fax Number:
*E-Mail Address:

Business Information
*Number of Owners:
*Number of Employees:
*Total Annual Gross Receipts:
*Payroll:
Business License Number
(if applicable):
License Type
(if applicable):
*Years of Experience:
How many years have you operated under the current business name?
Have you used any other business names during the past 5 years? yes no
Please describe the nature of your business and any unusual exposures:

Business Location Information
Property Address:
City:
State:
Zip Code:
County:
Total Square Footage of the Building Your Business Is In:
Square Footage Of Your Business Only:
How Many Stories:
Construction Type:  
Roof Type:  
Roof Updated: yes no  
If Yes, Year Roof was Updated:
Protection Distance:
Are There Smoke Detectors At This Location? yes no  
Fire Extinguisher: yes no
Deadbolts On All Doors? yes no
Circuit Breakers: yes no
Electrical Updated:
Plumbing Updated: yes no
If Yes, Year Plumbing was Updated:
Fire Sprinklers:
Burglar Alarm:
Fire Alarm:

Coverage Information
Current Insurance Company:
*Current Premium:
Losses-Claims in the last 5 years: 
If yes, date, amount paid and description of each loss-claim
*Liability Limit Requested:
Building Limit Requested:
Building Deductible Requested:
Business personal property (contents) coverage:
Contents Deductible Requested:
Loss of Income Limit Requested:

Additional Information
Additional Coverage Requests:
Questions or Comments
to help the Agent:

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