Allen C. Bentson Agency, Inc.
653 Forest Avenue Staten Island, NY 10310

(718) 442-1771

Applications
 
Please complete the following form and click Submit. We will contact you as soon as possible regarding your request.

Name of Firm 
Phone
Fax
Pager/Cell
Address
Tax ID #
Year Established
Locations Owned/Rented
Description of Operations
Area of Operations
Repair/Renovations
New
Commercial
Residential
Percentage of Business
Subcontractors and job cost
Payroll - excluding yourself
Receipts
Present Carrier
Include Expiration Date
Building Questionnaire
Location of Building
Age of Building
Construction
Limit Desired
Roof Age
Electrical: Age/Cir. Bkr.
Plumbing: Age
Heating: Type/Age
Square Footage:
Occupancy
Protection
Sprinkler System
Smoke Detectors
Burglar Alarm
Central Station Alarm
Emergency Light
Secondary Egress
Fire Escapes
Misc.
Pool
Playground
Underground Tanks
Loss Information
CONTRACTORS / DEVELOPERS SUPPLEMENTAL APPLICATION
Applicant's Name
Mailing Address
Location
Limits of Liability (Each Occurence)
Descriptions of Operations
Business Type
Corporation
Partenership
Joint Venture
Individual
No. of Years in Businees
Risk is a:
General Contractor
Subcontractor
Owner's Interest Only
Percentage of Work Performed in:
Loss History
Indicates all claims or occurences that may give rise to claims for the prior 5 years.
Type of Job
Do you Use Subcontractors?
Percentage of work subcontracted
Type of work subcontracted
Amount paid to subs

Losses
Put zero for no loss

2001=
2000=
2002=
1999=
1998=
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