Commercial Insurance Short Form

Commercial Insurance General Short Form

This is a general commercial form. If a particular question doesn't apply to your risk, please leave blank.
Named Insured
Entity type
Year entity formed
EIN #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Number of owners
Primary Contact

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Years experience
Description of business. Description of business operations/job performed for clients. (DETAILED PLEASE)
Website
Do you conduct any business activities in NYC or surrounding boroughs?

YesNo

Property Coverages
Do you own or rent your place of business?

OwnRent
*Estimated value of building(s)? (If Owned)
Estimated Square footage of main office

Building Information

	Answer
Year Built
Construction Type
Number of Stories
Primary Heat
Burglar Alarm Type
Fire Alarm Type
Percentage Sprinklered

Building Improvements

	Year
Wiring
Roofing
Plumbing
Heating

Estimated value of all property inside? (Including but not limited to furnishings, Machinery and inventory)

Itemized property (If required)

Number of additional locations
Do you own or rent at the additional locations?

OwnRentBoth

Financials and Employees
Estimated total gross revenue
Food receipts (If applicable)
Liquor receipts (If applicable)
Estimated gross payroll

Payroll

	Payroll Amount
Employees
Part Time
Subcontractors

Number of full time employees
Number of part time employees
Do you use subcontractors?
How many subcontractors do you use?
Annual subcontracted costs (Labor and material)

Autos

(If applicable)
Number of owned autos by entity
Are non-owned autos used for your business?

YesNo

Any other pertinent information?
Are you or entity the subject of any open litigations or lawsuits?

YesNo
Please provide a copy of existing policy or declaration pages

Cancelof
File upload any other pertinent information

Cancelof
How did you hear of us?
JFA representative

By submitting a quote request form you acknowledge that this is neither an offer to insure nor a guarantee of insurance.

Completion of this quote request form does not entitle you to a insurance policy.
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