Business Insurance in New York Tri-State Area and Nationwide: Payroll Services Plus Group

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	COMMERCIAL INSURANCE APPLICATION
COMPANY NAME:
STREET ADDRESS:
CITY:
STATE:
ZIP:
	COMPANY STATUS: (Please check one)
INDIVIDUAL:
CORPORATION:
PARTNERSHIP:
JOINT VENTURE:
SUBCHAPTER CORP.:
LIMITED CORP.:
NOT FOR PROFIT ORGANIZATION:
	CONTACT NUMBERS
WORK:
HOME:
CELL:
OTHER:
CURRENT POLICY EXPIRATION DATE:
NATURE OF BUSINESS: (Description of operation by premises)
FEIN OR SOCIAL SECURITY NUMBER:
ANNUAL PAYROLL:
YEAR BUSINESS STARTED:
ANNUAL SALES:
	POLICIES REQUESTED:
GENERAL LIABILITY:
PROPERTY:
WORKERS COMPENSATION:
COMMERCIAL AUTO:
UMBRELLA/EXCESS LIABILITY:
OTHER: (Specify)

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WE OFFER A WIDE RANGE OF INSURANCE SERVICES, IF IT IS NOT LISTED, PLEASE CALL. WE ALSO OFFER (PEO) PROFESSIONAL EMPLOYER SERVICES OR PAYROLL.