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

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Request Kiosk Insurance Quote

We are pleased to offer you a quotation on your insurance. Please fill out the form below & click on the submit button. Please provide me with the following information so I may provide you with an insurance quote and return via e-mail or fax. Fields marked with a red * are Required. Please provide us with a working email address, fax and phone number, so that we can contact you.


E-mail Address:

Address Line 1*:

Address Line 2:




Business Phone*:


Coverage Start Date:

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to your insurance interest?

Kiosk Insurance Details for Quote
Name of the Mall where your Business is located*:

Name of Your Business*:

Location address of Business*:

Brief Description of Your Business*:

Business Website Address:

Type of Business:

How long have you been in business?

Have you had any claims under this business?

Do you have any other business locations?

If Yes, what are the location addresses?

Do you have Employees?

If Yes, Number of Male Employees:

If Yes, Number of Female Employees:

Total estimated annual payroll for employees:
Estimated Annual Gross Sales:

Who do we send the certificate of insurance to, if policy is written?

Do you currently have a business and/or workers compensation insurance policy in place right now?

If yes, what is the name of the insurance company?

Have you had any other agent(s) quote your insurance coverage?

If yes, what is the insurance company name that was used?

If you would like us to quote inventory coverage, please provide us with what the dollar amount of your business personal property/Inventory at your location(s) (please note, if no value is provided we will not be quoting that coverage) $

Thank you for the opportunity to service your commercial insurance needs.

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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 SDN Insurance Agency, LLC is private and kept confidential.
Please refer to the Legal page for full details.

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