Instructions
Read Formly's
documentation
to learn how to implement this multi-step form.
Tell us about your business
Basic contact and location information for the business.
Business Name*
Year Established*
DBA (doing business as)
Business Phone*
Business Email*
Website
Business Address*
City*
State*
ZIP Code*
FEIN (Federal Employer ID)
Radius of Operation
Work in the 5 boroughs (NYC)?
Yes
No
Referred by
Step 1/4
Cancel
Next
Ownership & Background
Details about the business owner and their background.
Owner's full name*
Owner's phone*
Years of experience in field*
# of additional owners
Policy Status
Currently insured?
Yes
No
New venture?
Yes
No
5-year loss runs available?
Yes
No
Copies of current policies?
Yes
No
Step 2/4
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Next
Coverage needed & operations
Select all coverages required and describe what your business does.
Coverage Needs
General liability
Worker's compensation
Property / BOP
Disability
Excess liability
Commercial Auto
Commercial Umbrella
Equipment
Professional Liability (E&O)
Description of Operations*
Step 3/4
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Next
Finally, Employees & Financials
Workforce and revenue figures help us find accurate coverage options.
Total Employees*
# of Male Employees*
# Female Employees*
Total Annual Payroll*
Payroll Breakdown by Role
Total Revenue Projection Current Year ($)*
Prior Year Revenue ($)*
Additional Notes
Step 4/4
Back
Thank you! Your submission has been received!
A member of the JSM Brokerage team will be in touch shortly.
Questions? Call
(631) 765-2777
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info@jsmbrokerage.com
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