Glossary of Terms|Frequently Asked Questions|Emergency Contacts

About Us

Mission History Location Press Career Opportunities

Products & Services

Business Insurance Personal Lines Life and Employee Benefits Safety and Loss Control

Specialty Programs

Trucking Franchised Restaurants Habitational Programs APR Umbrellas

Claims

Emergency Claim Contacts Workers Comp Claim Form Disability Claim Form Vehicle Accident Report MV-104 Claim Form

For Clients

Glossary Frequently Asked Questions Emergency Claim Contacts Direct Billing Contacts Company Service Centers Certificate Request

Need information or a quote in a hurry? Simply fill out the quick form below and we'll contact you right away!

The B & G Group is proud to offer special programs for your industry:

	Trucking
	Franchised Restaurants
	Habitational Programs
	APR Umbrella

Learn More

Click here for a PDF version of this form

Please fill out the information below:

Person Requesting:

Company Name:

Date:

Time:

Insured Name (if different):

Phone Number:

Certificate Holder Information:

Name:

Phone:

Street Address:

City:

State:

Zip Code:

Attention:

Complete Description of Project including job name,job number, – This is Critical - We cannot proceed without this data –

Insurance Information:

Coverages Requested

General Liability	Auto	Work Comp
Property	Umbrella	NYS Disability
Other

Additional Wording Being Requested

Additional Insured Wording:

Loss Payable (regarding what and and please include account number):

Mortgagee (on what property and please include loan number) :

Please Mark All Additional Items Needed:

Thirty Day Cancellation

Primary Wording

"Endeavor to" wording deleted

Non-Contributory wording

Delivery Preferences

Mail Certificate:

Fax Certificate:

Fax Number:

Email Certificate:

Email Address: