CALL (516) 944-7520 FOR MORE INFO
 
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COMMERCIAL INSURANCE
General Liabilities Insurance
Commercial Auto Insurance
Workers Compensation Insurance
Disability Insurance
Group Insurance
Inland Marine Insurance
Bonds
Demolition Insurance
Contractors Insurance
Garage Insurance
Insurance for
Food Services
PERSONAL INSURANCE
Life Insurance
Auto Insurance
Health Insurance
Homeowners Insurance
Umbrella Insurance
Boating Insurance
Long Term Care Insurance

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FLOOD INSURANCE

CALL (516) 944-7520 FOR MORE INFO

We are licensed in these states: NY, NJ, PA, NH, CT, and MA.
We have been very success in writing policies for the following businesses: Electricians ~ Plumbers ~ Landscapers ~ Construction ~ Deli ~ Printers ~ Garage / Auto Mechanics ~ Distributors ~ Computer Stores

Applicant Information - GENERAL INFORMATION

First Name*
Last Name *
Property Address *
City*
State*
Zip*
E-Mail (REQUIRED):
E-Mail (again for accuracy): *
Phone: *
Fax

Dwelling Information
Year Home Built:
Was the building substantially improved (more than 50% increase in market value) at one time? If so, what year?
Is home currently under construction? Yes No
Home Square footage:
Number of units: 1 family Duplex
3 Family 4 Family
Type foundation: Slab at Ground Level
Basement, Finished
Basement, Unfinished
Elevated with enclosure
Elevated without enclosure
Type Roof: Shingle
Wood Shake
Tar/Gravel
Spanish Tile
Number of stories: One
1.5
Two
Three
Does home have a garage?
yes no
If yes to Garage, please describe if detached or attached, and if it containts any equipment such as washer/dryer, heating & air, etc.
Currently Insured? yes no
Name of Carrier & how long insured?
Do You Have an Elevation Certificate? yes no
Prior Claims? yes no
Describe claims in detail:


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Thank you for filling out this form COMPLETELY!


We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent
is to release quote information only to you. We will not give
your data to ANY other person or group for sales, marketing,
or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the
method you have chosen, and to release them from any
liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

 

 


 

 

 

 

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