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Complete the following information if you would like to obtain a Home Business Insurance quote. Please understand this is not an application. An application will be sent to you if coverage is desired.
All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Personal Information
What is your name?
What is your business name?
Business Name
What is your address?
What is your telephone number?
What is your fax number?
What is your email address?
Underwriting Information
What is your classification?
What is the nature of your business?
Nature of Business
How many owners?
Number of Owners
How many employees?
Number of Employees
What is the payroll amount of the owners?
Payroll of Owners
What is the payroll amount of the employees?
Payroll of Employees
What is the total annual gross?
Total Annual Gross Receipts
What are the total annual sub-costs?
Total Annual Sub-Costs
What is the business license number?
Business License Number
What is the license type?
License Type
Years of experience in this business?
Years of Experience
How many years have you operated under your current business name?
Years Operated Under Current Name
Have you used any other business names during the past 5 years?
Other Business Names
Yes No
Claims Information
Where there any losses or claims in the last 5 years?
Losses - Claims
Yes No
If yes, what is the date, amount paid and description of each loss or claim?
Coverage Information
What is the current insurance company?
How much are you paying now?
Amount Current Coverage
What is the business property amount?
Business Property Amount
What data processing amount?
Data Processing Amount
What is the liability amount?
Liability Amount
What is the policy deductible?
Policy Deductible
Are there any questions, comments or additional coverage required?
Questions, Comments or Additional Coverage
Best Time to Contact You
Please let us know the best time to call and discuss your quote.
Or specify other:
Platinum Resources, Inc

600 Old Country Road | Garden City, NY 11530
Phone 516-222-4942
Fax 516-745-0851
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