Commercial Underwriting Review Form  *New York State Only Information About You First Name: Last Name: Daytime Phone: Fax: E-Mail Address: Address: City: StateALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Code: Company Information Business Type: CorporationSole ProprietorshipPartnership Company Name: Number of Employees: Years in Business: Daytime Phone: Address: City: NY Zip Code: Premium Range: 0-$5,000$5,000-$10,000$10,000-$15,000$15,000 and Above Present Premium: Expiration Date: How Long in Force: Description of Business: Description of any Losses in Last Three Years (Date, Description, Amount Paid):