Homeowners Insurance Application

Please fill out the below form to the best of your ability for your FREE insurance quote. If you are unsure of any question you can leave it blank or call 516-541-2800 for more information. When you complete the form click “Submit” on the bottom and we will get back to you very shortly. Thank you !

Name
Address
Home
Cell
Email Address
Coverage’s  
Dwelling coverage (if known)
Is this a … New Purchase 

 
Current owner 

If "New" Purchase" Purchase Price $ 

 

Mortgage Amount $ 

What is the construction of
house?		 Frame 

 
Brick 

Year built?
Square feet?
Alarm system? Yes 

  No 
If "Yes" Burglar 

 
Fire 

 
Burglar & Fire 

Years of renovation  
Wiring
Plumbing
Heating
Roofing
Owner occupied? Yes 

 
No 

Tenant occupied? Yes 

 
No 

If "Yes", monthly rent
amount?
Swimming Pool Yes 

 
No 

If "Yes" In ground 

 
Above ground 

Distance to water? Less then 1 mile 

 
More then 1 mile 

Number of stories? 1 story 

 
2 story 

 
Tri-level 

Is there a basement? Yes 

 
No 

If "Yes" Finished 

 
Unfinished 

Do you own a dog? Yes 

  No 
If "Yes", breed & age
Do you have a trampoline on
your property?		 Yes 

 
No 
Which do you have in your
electric panel?		 Circuit Breakers 

 
Fuses 

Is the primary source of heat
thermostatically controlled?		 Yes 

 
No 

Do you have any prior
Homeowners claims?		 Yes 

 
No 

If "Yes", when & what
type of claim?
   
How did you hear about us?

 

Thank you. Please click submit below and we will get back to you with the best rate available in the New York area

 

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