P.O. Box 591, Plainview, NY 11803 Phone: 516-
55 W Ames Ct, Plainview, NY 11803 © 2010-
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If you are a licensed retail insurance agent or broker, you may place business with Empire State. Please complete the following Producer Questionnaire and forward same to us:
Request for Taxpayer Identification Number and Certification (IRS Form W-
A copy of our Producers Agreement and Questionnaire must also be completed:
Producer Agreement and Questionnaire
Upon completing both the Producer Questionnaire, and Producer Agreement and Questionnaire, please forward both back to us, using the information found on our contact page. Forward materials to either Dave Schepsman, or Brian Samway.
Thank you.
