York-Jersey Underwriters, Inc.

To receive an accurate quote, all information should be included.
Please supply an e-mail, fax, mailing address or call
(800) 392-6958.
**Please note, the submit button is at the end of the form.

Business Information:

Proprietor's Name:
Legal Name of Business:
Business Address:
City, State, Zip:
Phone:	Fax:
E-mail:	No. Locations:
No. Employees:	Sole Proprietor Partnership Corporation
Please Describe your business:
No. of years in business: (If less than 3 yrs, how many years experience does the proprietor have in this field?
Does the proprietor own or operate any other business? If so, please state
Describe all losses within the past 3 years, whether reimbursed or not, including date and amount of loss:
When does your present insurance expire? Month: Day: Year:
Has your insurance ever been canceled or non-renewed? If so, for what reason?

Location:

Street:	County:
City, State, Zip:
Area (Square Feet):	If Apartment (number of units):
Year built: (If over 30 yrs old, was the following updated? If so, when?) : wiring heating plumbing
Number of Stories	Building Value (if owned) $
Business Property $	Annual Sales / Receipts $
Annual Payroll $ If business is optical Goods, Hearing Aids or Drug Store, what is the percentage of Professional Sales to Annual Sales? %
Deductible: $250 $500 $1,000 $2,000 $2,500

Construction Type:

Exterior Walls: wood, stucco or brick veneer metal panels masonary (brick, concrete block, stone) fireproofed walls
Roof: wood metal panels noncombustible material reinforced concrete
Building have sprinklers?	Is there a swimming pool on location?
Is there a fire/burglar alarm? If so, what type? central station police department local

Coverage Information:

The Basic Spectrum Package (which includes: Business Liability, Business Income, Building and Business Personal Property, Equipment Breakdown) Please enter below other coverage's you request, include limits, if applicable. The limits shown are all included in The Hartford's Stretch Endorsement * Higher limits are available, indicate amount requested.
* Computers and Media	$10,000	$
* Accounts Receivable	$25,000	$
* Valuable Papers	$25,000	$
* Property in Transit	$15,000	$
* Personal Property of Others	$10,000	$
* Employee Dishonesty	$10,000	$
* Temperature Change	$10,000	$
Forgery or Alteration	$10,000
Backup of Sewers or Drains	$25,000
Personal Effects	$2,500
Indicate any other requested coverage's and amounts:

York-Jersey Underwriters ~ P.O. Box 810 ~ Red Bank, NJ 07701
Conveniently located one mile east of the Garden State Parkway at exit 109
In eastern Monmouth County N.J.
(732) 842-2012 ~ (800) 392-6958 ~ fax: (732) 530-7080
E-mail: sales@york-jersey.com

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