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Levy Insurance Agency
17 Bishop Hollow Road,
Suite B
Newtown Square, PA.
19073

Phone: 877-325-2242 Fax: 610-646-0750

Contractor Insurance

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   Serving Contractors in Pennsylvania and New Jersey.
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Compensation Quote Form
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Your Personal / Company Data:

Your Name:
Your Company's Name:
How Did Your Hear About Us?
Street Address:
City:
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Zip/Postal:
E-Mail (REQUIRED):
E-Mail again (for accuracy):
Phone:
Fax:
 


Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type NONE)
 
List Claims & Amounts Paid
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Years In Business:
 
Business type:
(proprietorship, corporation, etc.)
 
Do You Have a Safety Program?
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Do emplyoyees performing contracting average $22.00 per your or more? (Please describe):
 


 
Underwriting Information:
 
Describe IN DETAIL,
Your Business Operations:
 
Your Federal Tax ID#:
 
Payroll Class #1:
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class here:
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class here:
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Contact the Levy Insurance Agency at: tlevy@levyagency.com
17 Bishop Hollow Road, Suite B,     Newtown Square, PA.    19073
Toll Free Phone: 877-325-2242     Fax: 610-646-0750
Privacy Notice/Copyright Info.   |    © 2006 Insurance-Web-Sales
Questions or site-related technical problems, contact: tlevy@levyagency.com