Business Insurance – BigApple Insurance Brokerage – We make a difference in the moments that matter

BigApple Insurance Brokerage – We make a difference in the moments that matter

143-15 Hillside Ave., Jamaica, NY 11435
admin@bigappleinsurance.nyc

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+1 (718) 739-7500

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Please complete the form below to receive a rapid quote.

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Business Information:

Name*

Address*

Office Phone

Cell Phone*

Fax Number

Email*

Business/Company Detail:

Start Date*

MM slash DD slash YYYY

Federal Tax ID

# of Employees

Yearly Payroll

Yearly Gross Sales

Referred By:

President Information:

Name

Social Security Number

Date of Birth

MM slash DD slash YYYY

Prior Coverage (if applicable)

Prior General Liability Insurance Company

Policy #

Exp. Date

MM slash DD slash YYYY

Insurance Needed:

1. General Liability

Yes

No

2. Workers Comp

Yes

No

3. Disability

Yes

No

4. Umbrella

Yes

No

5. Hired/Non-owned Auto

Yes

No

Other - Builder’s Risk, OCP, OCIP, Equipment, Bonds, etc.

Are you working with:

1. DOT - Dept of Transportation

Yes

No

2. DOB - Dept of Buildings

Yes

No

3. NYCHA

Yes

No

4. HPD- Housing

Yes

No

5. DASNY

Yes

No

5. OGS

Yes

No

Please provide the following documents:

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

Driver's License

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

IRS SS4 form

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

Business Filing Receipt

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

Certificate of Incorporation

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

Prior coverage loss runs are very important. Please attach loss runs or email to admin@neib.us when available.

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

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CONTACT INFO

143-15 Hillside Ave., Jamaica, NY 11435
+1 (718) 739-7500
admin@bigappleinsurance.nyc

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