300 Spindrift Drive
Amherst, NY 14221
(800) 728-6362
(716) 633-3400








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We are pleased to offer you a quotation on your insurance. Please fill out the form below & click on the submit button. We will process your application and contact you with a detailed presentation.
Fields marked with a red * are Required. Please provide us with a working email address and phone number, so that we can contact you.

If you need assistance or wish to learn more about the program, call Eric Zillioux at 1 (800) 728-6362.

Name*:

E-mail Address:

Address Line 1*:

Address Line 2:

City*:

State*:

Zip*:

Business Phone*:

Fax:

Coverage Start Date*:


Add to our E-mail address book
for future newletters that pertain
to your insurance interest?


Business Address Line 1:

Business Address Line 2:

City:

State:

Zip:

Do You Own the Building?

Building Limit:

Contents Limit:

Do You Have Any High Value Equipment?

Years in Business:

Building Construction

Year Built:

Alarm Systems:
Fire Alarm
Burglar Alarm
Sprinkler System
Other
Interest:

Occupancy:

Do You have Employees?

Losses:


Do You Lease/Rent Equipment
such as Computer, Phones, etc.?

Item 1 Description / Value:

Item 2 Description / Value:

Item 3 Description / Value:

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By filling out this form, it in no way represents binding insurance coverage.
This application is used to quote your insurance only.
We may not provide insurance in your state and we will advise you in an e-mail if you do not qualify.
Any information that you provide to Scott Danahy Naylon is private and kept confidential.
Please refer to the Legal page for full details.


 
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