Contact Address:
Norton & Siegel, Inc.
PO Box 220
Babylon, NY 11702
"Remember, All Our Policies Come With an Agent!"
Underwriting Information:
Describe IN DETAIL, Your Business Operations:
Ownership & Payroll Data:
List Employee's Annual Payroll Here (if none, enter $0):
$
Insert # of Employees here:
Location & Sales Information:
Insert Annual Gross Revenues from this operation here:
$
Square Footage of office or business location:
Type of Building (wood frame, concrete, etc.):
Number of Stories:
Are there other business/residences in this building (describe)?:
Describe safety features (alarm, sprinklers, fire protection, etc):
Coverage Desired: (Check One Please)
The Coverage I Am Looking For:
Liability Only
Liability & Business Contents
Liability, Building & Contents Coverage
A Package Policy Including the Above, Plus Miscellaneous Coverages
NOTE: Don't worry if you are not exactly sure about
coverage type... we will suggest the best coverage for you - just try to tell us what you are looking for! (If we need more info. we will let you know.)
Business Contents Coverage: (The amount of your personal business property)
$
Building Coverage: (The amount of building coverage if you own your bldg.)
$
Miscellaneous Coverage: (List any special coverage peculiar to your business, such as Garagekeepers Legal, Loss of Earnings, Valuable Papers, etc.)
$
Select Any Optional coverages You'd Like Quoted:
Directors and Officers Coverage
Professional or Errors and Omission Coverage
Group Health Insurance Coverage
Workers Compensation Coverage
Business Auto/Vehicle Coverage
Business Property Coverage
Disability Coverage
Life Insurance Coverage
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