Get a Life Insurance Quote

One Simple Form - takes only 2-3 Minutes! Your Personal Data:

Your Name:
Property Address:
City:
Your "County" is?
State: (Must be New York)
Zip/Postal:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):


Dwelling Information

Year Home Built:
Home Square footage:

Is this Builder's Risk? (new home constr.)	NO YES

Month/Year home to be complete:

Number of units:	1 family Duplex

Type foundation:	Slab Crawlspace over slab Pier & Post Other (list in remarks)

Type Construction:	Frame Brick/Veneer Stone Other (list in remarks)

Type Roof:	Shingle Wood Shake Tar/Gravel Spanish Tile Metal Other

Number of stories:	One 1.5 Two Three

Do you have a trampoline?	Yes No

Do you own animals or pets?	Yes No
If yes, list type/for dogs, list breed:

Are You Near Brush Area?	Yes No

# of feet to nearest fire hydrant:	# of miles to nearest fire station:

Currently Insured?	Yes No
Name of Carrier & how long insured?

Prior Claims?	Yes No
Describe claims in detail:

Rate Your Credit History and Past Insurance Payment History: (Some companies products are based on your credit and payment history.)	Excellent Fair Poor Horrible

Primary Policyholder's Birthdate: (Some companies products offer discounts for certain age groups.)

Plumbing type:	Copper Galvanized Mixed (Copper/Galvanized)


Heating Type:	Gas (Propane or natural) Electric Oil (if oil, list tank location in remarks)

Circuit Breakers or fuses?	Breakers Fuses

# Bedrooms:		# Bathrooms:

# Fireplaces:		# Chimneys:

Special features (i.e., deck, air conditioning, alarm systems, pool, etc.)

Coverages:

Dwelling Cov. $		Contents $
Liability Cov. $		Deductible $ ($250, $500, $1,000, etc.)

Comments/Remarks (describe any scheduled jewelry, in-home business, oil tank location, or other special coverages/remarks here):

Send my quotation via:		E-Mail Fax Regular Mail Call Me By Phone


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