Personal Data
Last Name
First
Address
City
State
New York
Zip Code
Phone
Fax (optional)
E-Mail (Required)
Date of Birth
Social
Marital Status:
Currently Insured:
Dwelling Information
Year Home Built
Home Square Footage
Is this Builder's Risk? (new home construction)
Month/Year home to be completed (XX/XXXX)
Number of units
Select One
1 Family
Duplex
Construction Type
Select One
Frame
Masonry
Aluminum/Vinyl Siding
Roof Type
Select One
Shingle
Wood Shake
Tar/Gravel
Spanish Tile
Metal
Other (List in Remarks)
Stories
Select One
One
Two
1.5
Three
Other (List in Remarks)
Foundation Type
Select One
Slab
Crawlspace over slab
Basement
Other (list in remarks)
Feet to nearest fire hydrant
Do you own animals or pets?
If yes, list type (For dogs list breed)
Prior claims
Plumbing
Select One
Copper
Galvanized
Mixed
Other (List in Remarks)
Heating
Select One
Gas
Electric
Oil
Other (List in Remarks)
Fuel Tank Location
Select One
In-Ground
Basement
Garage
Other (List in Remarks)
Describe fuel tank location in remarks
Circuit breakers or fuses?
# of Bedrooms
# of Fireplaces
Special features
(Deck, air conditioning, alarm systems, pool, etc)
Comments / Remarks
(Please list all other types of features not covered above)
Coverages
Dwelling Coverage $
Contents $
Liability Coverage $
Deductible $
(250, 500, etc)
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