Allen C. Bentson Agency, Inc.
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Applications

 

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

Name of Firm
Address
Phone
Fax
Pager/Cell
Tax ID #
Year Established
Locations Owned/Rented
Description of Operations
Percentage of Business
Residential   
Commercial   
New   
Repair/Renovations   
Area of Operations   
Subcontractors and job cost
Payroll - excluding yourself
Receipts
Present Carrier
Include Expiration Date
Losses
Put zero for no loss
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 ?
Yes   
No   
Percentage of work subcontracted
Type of work subcontracted
Amount paid to subs



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653 Forest Avenue (Corner of Bement Avenue)
Staten Island, NY 10310
· Phone 718-442-1771 ·
· Fax 718-273-7695 ·
HOURS:
8:30 - 5:00 Monday - Friday
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