MRW Insurance Services

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General Information
Owners Name *
Email *
Business Phone

Full Name of Business
Location Address
Business Information
Business Type Corporation  Partnership  Individual  Other
How long in Business? (yrs)
# of Full-Time Employees
# of Part-Time Employees
Annual Payroll
Annual Expected Gross Sales
Requested Effective Date of Coverage (note completion of form does not bind coverage)
Number of Claims in Past 3 Years
Describe Claims from Past 3 Years
Property/Premises Information
Construction Type Frame - combustible material: frame walls with exterior covering of wood, shingles, brick, stucco
Joisted Masonry - masonry materials, e.g. brick cinderblock with combustible floor or roof
Non-Combustible - masonry materials with metal or non-combustible floor or roof
Fire-Resistive - masonry materials and with metal or other non-combustible floor and roof and coated with fire retardant material
Sprinklers Yes  No
Sq. Footage you occupy
Year Built
Year Roof Updated
Year Plumbing Updated
Year Heating Updated
Year Wiring Updated
Describe other Tenants in building (i.e. card shop, beauty salon, restaurant)
Building Coverage Yes  No
Limit of Insurance
Number of Stories
Building Personal Property Limit of Insurance
Computers & Media Limit of Insurance
Other Coverage Required (specify)
Do you print Lottery Tickets? Yes  No
* = Required Field
Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.

Visit or contact us at our headquarters at the
Matrix Corporate Park in Hauppauge, 
New York:

1373 Veterans Memorial Highway
Suite 8
Hauppauge, NY 11788

Phone: (631) 271-6600 
Fax: (631) 271-6618 

MRW Insurance Services is a full-service independent insurance agency offering a multitude of insurance products from top-rated companies to fulfill all your insurance needs. Our objective is to provide superior customer service and quality insurance solutions to all our customers. MRW is dedicated to getting you the best insurance products and services available today to protect you, your family and your business.

We have access to rates with more than 45 insurance companies to get you the best coverage at the lowest cost.

Our dedicated, professional staff members are ready to give you the personal attention you deserve.

Click here for a free quote on your insurance!

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