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
Full 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