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By Johnboy3241 | February 1, 2020 | 1

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INSURED BUSINESSES

(631) 224 1000

[email protected]

16 Station Rd Bellport, NY 11713

Monday-Friday 9:00 AM-5:00 PM

insured bars

insured clubs

insured yachts

insured restaurants

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Drop us a Line!

Name*
First Middle Last
Spouse Name
First Middle Last
Email Address*
Location Address*
Phone Number*
Construction Type*
Year built
Construction Materials
- Woodshake
- Asbestos Shingle
- Siding type
- Frame
- Masonry
Garage?
Garage Type:
Garage: # of Cars
Fireplace?*
Fireplace Material
Pool?
Pool: Above Ground?
Pool: In-ground?
Pool: Fenced?
Pool: Has a Diving Board?
Type of Heat
Heat: Is the oil tank in the ground?
Heat: How old is the oil tank?
Security:
- Smoke Alarms
- Fire Extiguisher
- Dead Bolts
- Central Station Alarm
- Burglar-Fire
Current Insurance Carrier
Message

Name*
First Middle Last
Email Address*
Phone Number*
Address
Street Address Address Line 2 City State ZIP Code
Vehicle Year*
Vehicle Make*
Vehicle Model*
Vehicle's Primary Use
Primary ZIP Location
Type of Security/Alarm
Owned or Leased?
U.S. Licence Status*
Years Licensed
Current Insurance Carrier
Message

Drop us a Line!

Corporate Name
Email Address
Location Address
DBA (Doing Business As)
Website Address
Business Phone
Home Phone
Number of Years at Current Location
Please enter a number from 1 to 100.
Nature of Bussiness
Area of Operation*
Detailed description of operations
Are you currently open
Tax ID Number
Total Annual Payroll
Number of Male/Female Employees
Current Insurance Carrier
Message

Drop us a Line!

Corporate Name
Company Officer
First Last
Email Address
Location Address
DBA (Doing Business As)
Website Address
Business Phone
Home Phone
Number of Years at Current Location
Please enter a number from 1 to 100.
Nature of Bussiness
Area of Operation*
Detailed description of operations
Are you currently open
Tax ID Number
Total Annual Payroll
Number of Male/Female Employees
Current Insurance Carrier
Message

Drop us a Line!

Corporate Name
Email Address
Location Address
DBA (Doing Business As)
Website Address
Business Phone Number
Home Phone Number
Other Number
Number of Years at Current Location
Please enter a number from 1 to 100.
If Less Than 3, Please List Experience
Seating Capacity
Number Of Bar Seats
Average Age of Clientele
Customer Square Footage
Maximum Number of Bar Tenders
Are any bouncers, door persons, crowd control, or security used?
If Yes, Please Explain Type
Last Call Given
Coverages
General Liability Limit (2 Million is Standard)
Liquor Liability Limit
Is Building Owned or Leased?
If Owned, Desired Limit Coverage
Contents Limit
Business Income Limit
Have there been any claims in the past five years?
Please Explain
Are you currently open
Current Insurance Carrier
Message

Drop us a Line!

Corporate Name
Email Address
Location Address
DBA (Doing Business As)
Website Address
Business Phone
Home Phone
Number of Years at Current Location
Please enter a number from 1 to 100.
Nature of Bussiness
Area of Operation*
Detailed description of operations
Are you currently open
Current Insurance Carrier
Message

Drop us a Line!

Corporate Name
Email Address
Location Address
DBA (Doing Business As)
Website Address
Business Phone Number
Home Phone Number
Other Number
Number of Years at Current Location
Please enter a number from 1 to 100.
If Less Than 3, Please List Experience
Seating Capacity
Number Of Bar Seats
Average Age of Clientele
Customer Square Footage
Maximum Number of Bar Tenders
Are any bouncers, door persons, crowd control, or security used?
If Yes, Please Explain Type
Last Call Given
Coverages
General Liability Limit (2 Million is Standard)
Liquor Liability Limit
Is Building Owned or Leased?
If Owned, Desired Limit Coverage
Contents Limit
Business Income Limit
Have there been any claims in the past five years?
Please Explain
Are you currently open
Current Insurance Carrier
Message

Drop us a line!

Corporate Name
Email Address
Location Address
DBA (Doing Business As)
Website Address
Business Phone
Home Phone
Number of Years at Current Location
Please enter a number from 1 to 100.
Nature of Bussiness
Number of Commercial Auto Vehicles*
Area of Operation*
Detailed description of operations
Are you currently open
Is Building owned or leased
Current Insurance Carrier
Message

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