Secure Quote Request

Insured Name*
Business Name
Phone Number*
Email Address*
Business Website Address
Address
Street Address Address Line 2 City State ZIP Code
Tax ID Number
Effective Date From
Date Format: MM slash DD slash YYYY
Effective Date To
Date Format: MM slash DD slash YYYY
Desired Renewal / Premium (Enter "Don't Know" If Not Sure)
Current Insurer
Years in Business
Legal Entity (LLC, Corp, Partnership, etc.)
Nature of Business / Description of Operations
What Type of Policy Do You Need?*
- Business Owners
- Commercial Auto
- Workers' Compensation
Business Owners Policy / All Other Policy Types
Owner's Management Experience in Years
Liability Limits Desired
- 300K
- 500K
- 1M
Total Gross Payroll
Total Sales
Hours of Operation - Open Time
Hours of Operation - Close Time
Building Own or Lease
- Own
- Lease
Building Value
Year Building Built
Type of Construction
Number of Stories
Square Feet
Burglar Alarm
- Yes
- No
Fire Alarm
- Yes
- No
Is your loss ratio (average annual losses/quoted premium) less than 40%?
- Yes
- No
Number of Full Time Employees
Number of Part Time Employees
Do you use temp workers?
- Yes
- No
Do you use sub-contractors?
- Yes
- No
Any outstanding suits or liens against the business and/or any bankruptcies in the last 3 years?
- Yes
- No
Commercial Auto Policy
Garaging Address of Vehicle (If different from above)
Street Address Address Line 2 City State ZIP Code
How is Vehicle Used
Liability Limits Desired
Gross Vehicle Weight
Physical Dam Deductibles Desired
Radius of Operation
Vehicle Information
Year Make Model Cost New

Press the "+" symbol to add another vehicle.
Driver Information
Full Name License # Date of Birth

Press the "+" symbol to add another driver.
Coverages Needed (Check all that apply)
- Additional PIP
- Medical Payment
- Towing/Labor
- Comprehensive
- Collision
- Hired/Non-Owned Auto Rental
Please List All Accidents in Past 3 Years

Press the "+" symbol to add another accident.
Please List All Moving Violations in Past 3 Years

Press the "+" symbol to add another moving violation.
Have you been canceled for non-payment of premium within the last 3 years?
- Yes
- No
All price indications are pending favorable loss history for prior 3 years and favorable MVRs.
Workers' Compensation Policy
Liability Limits Desired
- 100/500/100
- 500/500/500
- 1M/1M/1M
Class & Payroll
Class Code # Employees Payroll ($) Description

Press the "+" symbol to add another class.
Have you been in operation for at least 3 years?
- Yes
- No
Do you have prior workers' compensation coverage?
- Yes
- No
Hours of Operation - Open After 6 PM?
- Yes
- No
Hours of Operation - Open After 9 PM?
- Yes
- No
Hours of Operation - Open After Midnight?
- Yes
- No
Hours of Operation - Open After 2 AM?
- Yes
- No
Is your loss ratio (average annual losses/quoted premium) less than 40%?
- Yes
- No
Do employees handle hazardous materials?
- Yes
- No
Do employees ever work at heights exceeding 15 feet?
- Yes
- No
Are employees involved in trucking or transportation operations?
- Yes
- No
Number of Full Time Employees
Number of Part Time Employees
Maximum number of employees working at one time at a location?
Comments & Agreement
Additional Comments or Questions?
By checking this box, I understand that the information provided above (and, possibly, additional information gathered later) is to be used to get non-binding pricing indication. Coverage cannot be bound without additional information, including a signed application.*
- I Agree

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New Jersey Office

Flagship Insurance

65 South Main Street
Suite C200
Pennington, New Jersey 08534

Phone: (609) 818-9534

Fax: (609) 818-9535

Google Maps

New York Office

Flagship Insurance

111 North Central Avenue
Suite 350
Hartsdale, New York 10530

Phone: (609) 808-9534

Fax: (609) 818-9535

Google Maps

Massachusetts Office

Flagship Insurance

651 Orchard Street
Suite 301
New Bedford, Massachusetts 02744

Phone: (508) 994-9688

Fax: (508) 991-5461

Google Maps

Lake Worth Office

Flagship Insurance

4615 10th Avenue North
Lake Worth, Florida 33463

Phone: (561) 965-0700

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West Palm Beach Office

Flagship Insurance

400 Village Blvd
Suite 3
West Palm Beach, Florida 33409

Phone: (561) 686-5700

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Flagship Insurance provides Work Comp/Business Insurance to all of New Jersey, New York, and Massachusetts, including Pennington, Hartsdale, and New Bedford.

Insurance Website Design

Year	Make	Model	Cost New

Full Name	License #	Date of Birth

Class Code	# Employees	Payroll ($)	Description

Secure Quote Request

Business Owners Policy / All Other Policy Types

Commercial Auto Policy

Workers' Compensation Policy

Comments & Agreement