Request A Quote: Home Owner's
Homeowners
General Information
Quote Description
New York
State
Effective Date
Primary
Secondary
Seasonal
Residence Type
Current/Prior Insurance
Continuously Insured 1 Year
No
Yes
Insured Information
Name
Address
E-mail
Phone
Insured Date of Birth
Age
Gender
Male
Female
No
Yes
Insured or Spouse Empolyed Full Time?
Occupation
Coverage Information
Dwelling Value
Medical Payments
Personal Liability
Deductible
$1000
$2000
$3000
$4000
$5000
$100,000
$200,000
$300,000
$400,000
$500,000
$250
$500
$1000
Property Information
Frame
Masonry
Construction
Year Built
Number of Families
No
Yes
Distance to Fire Hydrant
Copper/PVC Plumbing?
No
Yes
Circuit Breaker?
Miles to Fire Department
No
Yes
Heating Type
Smoke Detectors?
Is roofing 15 years old or less?
No
Yes
No
Yes
Dead Bolt Locks?
No
Yes
Fire Extinguisher?
Loss Information
Claims Made in the Last Five Years (list maximum of three)
Year
Amt Paid
Amt Paid
Year
Year
Amt Paid
Company Questions
Do you own a dog?
No
Yes
If so, what type(s)?
Do you own a pool?
No
Yes
If so, does it have a diving board?
No
Yes
Do you own a trampoline?
No
Yes
Do you own a wood burning stove?
No
Yes
