Name: Intermarket Insurance Agency
Address: 205 East Main St, Huntington, NY, 11743, US
Telephone: (631) 421-2424

General Information
Legal Entity (Corp, LLC, Partnership, etc.)*
Your Legal Business Name*
D/B/A, if applicable
Your Name*
Phone Number*
Fax Number
Email Address*
Web Address
Center Location Address*
Street Address Address Line 2 City State ZIP Code
Billing Address (If Different Than Center Location Address)
Street Address Address Line 2 City State ZIP Code
Do you conduct tutoring in your primary location?*
- Yes
- No
Information for Additional Locations
How many additional locations do you have?*
- None
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
Additional Location One
Corporate Name & DBA:
Date to add new location:
MM slash DD slash YYYY
Location Address:
Street Address Address Line 2 City State ZIP Code
Do you own the building this Center is in?
- Yes
- No
Year building was built:
Square Footage:
Number of Stories:
Linear feet of exterior glass:
Construction of building:
Does your Center have a Central Station Fire/Burglar Alarm?
- Yes
- No
Does your Center have a Sprinkler System?
- Yes
- No
Business Property Limit:
Tenants Improvements & Betterments:
Do you currently have Workers Compensation coverage for this location?
- Yes
- No
Current Workers Compensation coverage information:
Carrier Expiration Date Annual Premium
Additional Location Two
Corporate Name & DBA:
Date to add new location:
MM slash DD slash YYYY
Location Address:
Street Address Address Line 2 City State ZIP Code
Do you own the building this Center is in?
- Yes
- No
Year building was built:
Square Footage:
Number of Stories:
Linear feet of exterior glass:
Construction of building:
Does your Center have a Central Station Fire/Burglar Alarm?
- Yes
- No
Does your Center have a Sprinkler System?
- Yes
- No
Business Property Limit:
Tenants Improvements & Betterments:
Do you currently have Workers Compensation coverage for this location?
- Yes
- No
Current Workers Compensation coverage information:
Carrier Expiration Date Annual Premium
Additional Location Three
Corporate Name & DBA:
Date to add new location:
MM slash DD slash YYYY
Location Address:
Street Address Address Line 2 City State ZIP Code
Do you own the building this Center is in?
- Yes
- No
Year building was built:
Square Footage:
Number of Stories:
Linear feet of exterior glass:
Construction of building:
Does your Center have a Central Station Fire/Burglar Alarm?
- Yes
- No
Does your Center have a Sprinkler System?
- Yes
- No
Business Property Limit:
Tenants Improvements & Betterments:
Do you currently have Workers Compensation coverage for this location?
- Yes
- No
Current Workers Compensation coverage information:
Carrier Expiration Date Annual Premium
Additional Location Four
Corporate Name & DBA:
Date to add new location:
MM slash DD slash YYYY
Location Address:
Street Address Address Line 2 City State ZIP Code
Do you own the building this Center is in?
- Yes
- No
Year building was built:
Square Footage:
Number of Stories:
Linear feet of exterior glass:
Construction of building:
Does your Center have a Central Station Fire/Burglar Alarm?
- Yes
- No
Does your Center have a Sprinkler System?
- Yes
- No
Business Property Limit:
Tenants Improvements & Betterments:
Do you currently have Workers Compensation coverage for this location?
- Yes
- No
Current Workers Compensation coverage information:
Carrier Expiration Date Annual Premium
Additional Location Five
Corporate Name & DBA:
Date to add new location:
MM slash DD slash YYYY
Location Address:
Street Address Address Line 2 City State ZIP Code
Do you own the building this Center is in?
- Yes
- No
Year building was built:
Square Footage:
Number of Stories:
Linear feet of exterior glass:
Construction of building:
Does your Center have a Central Station Fire/Burglar Alarm?
- Yes
- No
Does your Center have a Sprinkler System?
- Yes
- No
Business Property Limit:
Tenants Improvements & Betterments:
Do you currently have Workers Compensation coverage for this location?
- Yes
- No
Current Workers Compensation coverage information:
Carrier Expiration Date Annual Premium
Additional Location Six
Corporate Name & DBA:
Date to add new location:
MM slash DD slash YYYY
Location Address:
Street Address Address Line 2 City State ZIP Code
Do you own the building this Center is in?
- Yes
- No
Year building was built:
Square Footage:
Number of Stories:
Linear feet of exterior glass:
Construction of building:
Does your Center have a Central Station Fire/Burglar Alarm?
- Yes
- No
Does your Center have a Sprinkler System?
- Yes
- No
Business Property Limit:
Tenants Improvements & Betterments:
Do you currently have Workers Compensation coverage for this location?
- Yes
- No
Current Workers Compensation coverage information:
Carrier Expiration Date Annual Premium
Additional Location Seven
Corporate Name & DBA:
Date to add new location:
MM slash DD slash YYYY
Location Address:
Street Address Address Line 2 City State ZIP Code
Do you own the building this Center is in?
- Yes
- No
Year building was built:
Square Footage:
Number of Stories:
Linear feet of exterior glass:
Construction of building:
Does your Center have a Central Station Fire/Burglar Alarm?
- Yes
- No
Does your Center have a Sprinkler System?
- Yes
- No
Business Property Limit:
Tenants Improvements & Betterments:
Do you currently have Workers Compensation coverage for this location?
- Yes
- No
Current Workers Compensation coverage information:
Carrier Expiration Date Annual Premium
Additional Location Eight
Corporate Name & DBA:
Date to add new location:
MM slash DD slash YYYY
Location Address:
Street Address Address Line 2 City State ZIP Code
Do you own the building this Center is in?
- Yes
- No
Year building was built:
Square Footage:
Number of Stories:
Linear feet of exterior glass:
Construction of building:
Does your Center have a Central Station Fire/Burglar Alarm?
- Yes
- No
Does your Center have a Sprinkler System?
- Yes
- No
Business Property Limit:
Tenants Improvements & Betterments:
Do you currently have Workers Compensation coverage for this location?
- Yes
- No
Current Workers Compensation coverage information:
Carrier Expiration Date Annual Premium
Additional Location Nine
Corporate Name & DBA:
Date to add new location:
MM slash DD slash YYYY
Location Address:
Street Address Address Line 2 City State ZIP Code
Do you own the building this Center is in?
- Yes
- No
Year building was built:
Square Footage:
Number of Stories:
Linear feet of exterior glass:
Construction of building:
Does your Center have a Central Station Fire/Burglar Alarm?
- Yes
- No
Does your Center have a Sprinkler System?
- Yes
- No
Business Property Limit:
Tenants Improvements & Betterments:
Do you currently have Workers Compensation coverage for this location?
- Yes
- No
Current Workers Compensation coverage information:
Carrier Expiration Date Annual Premium
Additional Location Ten
Corporate Name & DBA:
Date to add new location:
MM slash DD slash YYYY
Location Address:
Street Address Address Line 2 City State ZIP Code
Do you own the building this Center is in?
- Yes
- No
Year building was built:
Square Footage:
Number of Stories:
Linear feet of exterior glass:
Construction of building:
Does your Center have a Central Station Fire/Burglar Alarm?
- Yes
- No
Does your Center have a Sprinkler System?
- Yes
- No
Business Property Limit:
Tenants Improvements & Betterments:
Do you currently have Workers Compensation coverage for this location?
- Yes
- No
Current Workers Compensation coverage information:
Carrier Expiration Date Annual Premium
Additional Location Eleven
Corporate Name & DBA:
Date to add new location:
MM slash DD slash YYYY
Location Address:
Street Address Address Line 2 City State ZIP Code
Do you own the building this Center is in?
- Yes
- No
Year building was built:
Square Footage:
Number of Stories:
Linear feet of exterior glass:
Construction of building:
Does your Center have a Central Station Fire/Burglar Alarm?
- Yes
- No
Does your Center have a Sprinkler System?
- Yes
- No
Business Property Limit:
Tenants Improvements & Betterments:
Do you currently have Workers Compensation coverage for this location?
- Yes
- No
Current Workers Compensation coverage information:
Carrier Expiration Date Annual Premium
Additional Location Twelve
Corporate Name & DBA:
Date to add new location:
MM slash DD slash YYYY
Location Address:
Street Address Address Line 2 City State ZIP Code
Do you own the building this Center is in?
- Yes
- No
Year building was built:
Square Footage:
Number of Stories:
Linear feet of exterior glass:
Construction of building:
Does your Center have a Central Station Fire/Burglar Alarm?
- Yes
- No
Does your Center have a Sprinkler System?
- Yes
- No
Business Property Limit:
Tenants Improvements & Betterments:
Do you currently have Workers Compensation coverage for this location?
- Yes
- No
Current Workers Compensation coverage information:
Carrier Expiration Date Annual Premium
Additional Location Thirteen
Corporate Name & DBA:
Date to add new location:
MM slash DD slash YYYY
Location Address:
Street Address Address Line 2 City State ZIP Code
Do you own the building this Center is in?
- Yes
- No
Year building was built:
Square Footage:
Number of Stories:
Linear feet of exterior glass:
Construction of building:
Does your Center have a Central Station Fire/Burglar Alarm?
- Yes
- No
Does your Center have a Sprinkler System?
- Yes
- No
Business Property Limit:
Tenants Improvements & Betterments:
Do you currently have Workers Compensation coverage for this location?
- Yes
- No
Current Workers Compensation coverage information:
Carrier Expiration Date Annual Premium
Additional Location Fourteen
Corporate Name & DBA:
Date to add new location:
MM slash DD slash YYYY
Location Address:
Street Address Address Line 2 City State ZIP Code
Do you own the building this Center is in?
- Yes
- No
Year building was built:
Square Footage:
Number of Stories:
Linear feet of exterior glass:
Construction of building:
Does your Center have a Central Station Fire/Burglar Alarm?
- Yes
- No
Does your Center have a Sprinkler System?
- Yes
- No
Business Property Limit:
Tenants Improvements & Betterments:
Do you currently have Workers Compensation coverage for this location?
- Yes
- No
Current Workers Compensation coverage information:
Carrier Expiration Date Annual Premium
Additional Location Fifteen
Corporate Name & DBA:
Date to add new location:
MM slash DD slash YYYY
Location Address:
Street Address Address Line 2 City State ZIP Code
Do you own the building this Center is in?
- Yes
- No
Year building was built:
Square Footage:
Number of Stories:
Linear feet of exterior glass:
Construction of building:
Does your Center have a Central Station Fire/Burglar Alarm?
- Yes
- No
Does your Center have a Sprinkler System?
- Yes
- No
Business Property Limit:
Tenants Improvements & Betterments:
Do you currently have Workers Compensation coverage for this location?
- Yes
- No
Current Workers Compensation coverage information:
Carrier Expiration Date Annual Premium
Please Complete if You Operate Out of a Center
Square footage of your center:
Construction of the building this center is in:
How many stories is this building?
What year was this building built?
Is this center the sole occupant of this building?
- Yes
- No
Does this center have fire sprinklers in it?
- Yes
- No
Does this center have a central station burglary alarm?
- Yes
- No
Replacement cost of your center's buildout (improvements/betterments):
Replacement cost of your center's contents:
Property deductible desired:
Landlord's name if to be added as additional insured:
Landlord's Address:
Loss payee if to be added for leased / financed property:
Landlord's Address:
Please Answer Each Question
What is your Federal ID Number (FEIN)?
Will you tutor special needs students?
- Yes
- No
Will you conduct in-home tutoring?
- Yes
- No
If yes, please describe the types of student and the accommodations that have been made for them.
Is there a policy in place for dispensing medicine to students?
- Yes
- No
- N/A
Number of years in business?
Number of years as an educator?
Do you use volunteers?
- Yes
- No
Do you currently have liability insurance?
- Yes
- No
Current insurance premium:
Current insurance carrier:
Current expiration date of coverage:
MM slash DD slash YYYY
Do you currently have workers compensation insurance?
- Yes
- No
Current insurance premium:
Current insurance carrier:
Current expiration date of coverage:
MM slash DD slash YYYY
Do you have a vehicle registered to your business?
- Yes
- No
If yes, do you have a commercial auto policy in place?
- Yes
- No
Have you had any insurance claims in the past 4 years?
- Yes
- No
I hereby WARRANTY the above statement to be true (Please initial)
If you need PROPERTY coverage for your office - How much?
Are your teachers paid on a W-2 (Employees) as opposed to a 1099 (Independent Contractors)?
- Yes
- No
Will all tutors, full and part-time, 1099 contractors and volunteers strictly follow the curriculum set forth by you?
- Yes
- No
Annual tutor payroll?
Annual clerical/office payroll?
Other payroll?
Experience Mod # if you have one:
Do own and/or operate another business outside of the tutoring business associated to this application?
- Yes
- No
If Yes, please explain:
Do you want to be EXCLUDED from Workers Compensation coverage, if allowed by state law?
- Yes
- No
Please Answer "YES" or "NO" to the following questions. Answers are REQUIRED in order for us to process a quote.
Do you retain copies of your tutors' Personal Auto Policy(PAP)? PAP Limits must be minimum 100/300/50*
- Yes
- No
Have there been any claims, complaints or accusation of injury, abuse or molestation of any children?*
- Yes
- No
Does your employment application ask if the applicant has ever been convicted of any crime, including sex-related or child abuse related offenses?*
- Yes
- No
Do you verify employment references?*
- Yes
- No
Do you conduct personal interviews?*
- Yes
- No
Do you perform criminal background checks on all full and part-time employees, 1099 contractors and volunteers including foreign staff?*
- Yes
- No
Are they repeated every 3 years?*
- Yes
- No
If NO how often will they be conducted?*
Have you had a criminal background check conducted on yourself?*
- Yes
- No
If yes, can you please provide proof.*
Will there always be at least one parent/responsible adult present during in-home and off premises tutoring?*
- Yes
- No
Staff to child ratio?*
Is there a formal written policy regarding corporal punishment?*
- Yes
- No
Are you and your staff trained to recognize signs of abuse?*
- Yes
- No
Is there a procedure in place that helps mitigate situations that could lead to abuse allegations.*
- Yes
- No
Is there a formal policy requiring incident reporting?*
- Yes
- No
Number of school district you are contracted with, or intend to be contracted with in the coming year?*
- 1 - 5
- 6 -10
- 11+
Will your type of tutoring be strictly academic?*
- Yes
- No
Will any driver training classes be provided?*
- Yes
- No
Will there be any type of tutoring conducted with power equipment, machinery, woodworking, welding or chemicals?*
- Yes
- No
Sporting Activities*
- Yes
- No
Field Trips*
- Yes
- No
Fundraising*
- Yes
- No
Other*
- Yes
- No
Other*
If yes to any of the above please give a detailed explanation.*
Total number of hours of instruction given last year:*
What were your annual gross receipts last year?*
Average number of students you will tutor on a daily basis?*
Warranty*
- I hereby WARRANTY the above information to be true
*
Quotes generally take 2-3 business days to turn around. If you are up against a district deadline and need this sooner please provide us with the deadline date.
Deadline Date:

Mathnasium Form Page

General Information

Information for Additional Locations

Additional Location One

Additional Location Two

Additional Location Three

Additional Location Four

Additional Location Five

Additional Location Six

Additional Location Seven

Additional Location Eight

Additional Location Nine

Additional Location Ten

Additional Location Eleven

Additional Location Twelve

Additional Location Thirteen

Additional Location Fourteen

Additional Location Fifteen

Please Complete if You Operate Out of a Center

Please Answer Each Question

Please Answer "YES" or "NO" to the following questions. Answers are REQUIRED in order for us to process a quote.

Quotes generally take 2-3 business days to turn around. If you are up against a district deadline and need this sooner please provide us with the deadline date.