New business application

Business Name *

First Name

Last Name

Phone *

Email *

Policy Upload

Line of business *

Any losses?

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Do you wan to submit? answer yes and submit form, or no and complete the rest of the form.

yes

no

Type of Business

FEIN #

Mailing Address

City

State

Postal code

Do you want to add location info?

Yes

No

Location Address 1

Location City 1

Loc State 1

Loc Zip code 1

Square Feet

any vacancies? % occupied?

any commercial occupancies? if yes square feet

construction type

Year Built

Year Electrical Update

year plumbing update

Year Roof Updated

Year Heating Updated

did building ever gone through a Gut Rehab?

Number of Units

number of stories?

is building sprinklered

% Sprinklered

circuit breakers for electrical?

smoke/ carbon monoxide detectors

yes

no

Central Station Burglar Alarm?

yes

no

Central station fire alarm?

Yes

No

do you have a 2nd location?

yes

no

Location Address 2

Location City 2

Location State 2

Location Zip 2

any vacancies? % occupied? 2

square feet 2

any commercial occupancies? if yes square feet 2

construction type 2

Year built 2

year plumbing updated2

year heating updated 2

year roof updated 2

year electrical updated 2

did building ever gone through a Gut Rehab? 2

For Condominiums what % is owner occupied?2

number of stories? (2)

% sprinklered 2

is building sprinklered? 2

# of units 2

circuit breakers for electrical? 2

Central Station Burglar Alarm? 2

yes

no

Central station fire alarm? 2

yes

no

Additional Info

Contact Information

6 Lemberg Ct unit 405, Monroe, NY 10950

rivky@upfrontcoverage.com

845-799-1748