"Insurance Quote from NIE Insurance, Dry Cleaner and Coin Laundry Insurance Specialists"

Quote Request
Business Name:
FEIN:
Address:
Address (con't)
City:
State:
Zipcode:
Telephone(xxx)xxx-xxxx:
Fax:
Type of Business:
Contact Name:
Email Address:
Current Policy Expiration:
Location Address:
Location Address (con't)
Location City:
Location State:
Location Zipcode:
Building Construction:
Location Type:
Building Value:	$
Personal Property Value:	$
Gross Sales Receipts:	$
Dry Cleaning Receipts:	$
Long Term Storage Value:	$
Type of Solvent:
Claims in Last Five Years:
Does entity own any unincorporated business, in whole or in part, not listed on this application?
Yes No
If yes, describe:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. In NY they shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
How would you like to receive your quote?	FAX Mail
Do you have additional locations you would like a quote for?	Yes: No:

Quote Request