New Era Insurance Brokerage
197-02 Hillside Ave, NY 11423, USA
info@neib.us
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Insurance Form
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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