AUTO REPAIR
INSURANCE
Prospect is best described as:
Contractor
Any Other Type of Business
Business Description
Building Coverage
Yes
No
What Types of Insurance are you Interested in?
Business Owners Policy / Package Policy
General Liability
Special Events Policy
Contents, Building, Tools
Employment Practices Liability
Workers Compensation
Directors and Officers Liability
Business Automobiles
Professional Liability
Umbrella
N.Y. State DBL
I'm Not Sure What I Need??
Cyber Liability
Applicant's Information
Applied Code:
Distance to Coast
This is not to be completed
Business Name
*
(DOING BUSINESS AS)
Contact's Name
Phone
*
Email
*
BUSINESS NAME continued, ....list all related names of business
Address
*
City
*
State
*
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
*
COUNTY
OWNERSHIP TYPE
Select
Individual
Partnership
Corporation
LLC
Other
YEAR BUS. STARTED
Select
NEW - 2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
Before 1990
YEARS EXPERIENCE
BUSINESS OPERATED
OUT OF A HOME
Select
Yes
No
Township
Website
OWN ANY OTHER BUS.
Select
Yes
No
Coverage Date
Not Sure Of Date
In Business for
Years or New
#
Yrs Experience
Applicant Owns Other Business
Yes
No
Agent's Information
Agent Name
*
Contact
Contact Email
*
Contact Phone
*
Butwin Agent Code
Choose Code
Other
Property Info
Construction
Frame
Joisted Masonry
Non-Combustible
Masonry/Non Combustible
Fire Resistive
Other building tenants
Yes
No
How many tenants
SQ Ft and Description of each
