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Agent!

 
E-mail Questions to:
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andsiegel.com

 

Toll-Free: 1-866-669-0365
Phone: 1-631-669-0365
Fax: 1-631-669-0158

Contact Address:
Norton & Siegel, Inc.
PO Box 220
Babylon, NY 11702

"Remember, All Our Policies Come With an Agent!"
 

On-Line Contractor
General Liability Quote Form
One Simple Form - takes only 2-3 Minutes!

Your Name:
BUSINESS Name:
Mailing Address:
City:
State: (Must be New York)
Zip/Postal:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
 
Business Underwriting Information
Type of operation:
Describe operations in detail:
License class:
License Number:
Social Sec. or Employer ID#:
 
Limit of Liability
Coverage Requested?
$300,000
$500,000
$1 Million
 

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
 
 
Currently Insured? Yes No
Name of Carrier & how long insured?
Prior Claims? Yes No
Describe claims in detail:
 
Years in business:
Years experience in field:
Percentage of work residential:
Percentage of work commercial:
 
Number of Active Owners:
Number of Employees: 0   1   2   3+
Annual Employee Payroll: $
Annual Gross Sales: $
 
Do you subcontract work? Yes No
(If yes, what percentage of your work
is subbed, and what kind of work?)
Do you do foundation work? Yes No
Do you work on condos? Yes No
Employees paid over $18/hour? Yes No
Do you have a safety program? Yes No

 
Comments/Remarks:
 
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We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release them from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

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Norton & Siegel, Inc. | PO Box 220 | Babylon, NY 11702 | Phone: 1-631-669-0365 | Fax: 1-631-669-0158
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