Nigro's Insurance Form


Contact Information:
Name: _______________________________________________________________________________________________
Phone: Email: Fax: ______________

AUTO

Name of Drivers: _______________________________________________________________________
DOB: ___________________________________________________
Driver’s License # _________________________________________
Address: _____________________________________________________________________________
City: _________________________________State:___________________________Zip Code_________
Social Security #________________________________________________
Car Make/Model OR VIN #:_______________________________________
Claims: Please briefly list any accidents that still may be listed on your record
1. ________________________________________________________________________________
2. ________________________________________________________________________________
3. ________________________________________________________________________________
Occupation: ________________________________________________________________________
Vehicle Use: Business/Pleasure _________________________________________________________

HOME/CONDO/RENTER’S

Name on the Deed/Lease: ______________________________________________________________
Structure Type: _______________________________________________________________________
DOB: _______________________________________________________________________________
Social Security: _______________________________________________________________________
Address: ____________________________________________________________________________
City: ________________________________State:_________________________Zip Code:_________
Claims: Please briefly list any accidents that still may be listed on your record
1. ___________________________________________________________________________________
2. ___________________________________________________________________________________
3. ___________________________________________________________________________________

COMMERCIAL

First Insured Name: ____________________________________________________________________
Corporation ID Number: ________________________________________________
EIN Number: __________________________________________________________
Partner Names: ________________________________________________________
Years in Business: ______________________________________________
Annual Gross Receipts: __________________________________________
Number of Employees/Part-time/Full-time:__________________________________________________
Square Footage of Building: _______________________________________________________
Number of Vehicles: _____________________________________________________________
Type of Policy Currently: __________________________________________________________
Current Policy’s Expiration Date: ____________________________________________________
Claims: Please briefly list any accidents that still may be listed on your record
1. ___________________________________________________________________________________
2. ___________________________________________________________________________________
3. ___________________________________________________________________________________

OTHER INSURANCE NEEDS:_________________________________________________________________

    This is a required question