Member Brokerage Services - Homeowners Insurance Quote
General Information
(Required *)
Name
*
Address
*
City, State, Zip
,
County
E-mail Address
Day Phone
*
Evening Phone
*
Best time to call
AM
PM
Occupation
How long at your current job?
Current Homeowners Insurance Company (not agency)
Company Name
Policy Expiration Date
/
/
Amount Insured For
$
Number of claims in the past 5 years?
How long at your present address?
Square Footage of Home
(excluding garage and basement)
Year Home was Built
Structure Information
Type
1 Story
1 1/2 Story
2 Story
Split Level
Bi-Level
Other
Construction
Framed or Stucco
Masonry or Veneer
Masonry
Other
Roof
Asphalt Shingle
Wood Shingle
Tile or Slate
Other
Age of roof in years?
Foundation
Basement
Crawl Space
Slab
Other
Garage
1 Car
2 Car
3 Car
4 Car
None
Attached
Detached
Basement
Built-In
Car Port
Other
Features
Bathrooms
Full:
Half:
Basement
None
Finished
Unfinished
Sq Ft:
Deck/Porch/Patio
Deck Sq Ft:
Porch Sq Ft:
Patio Sq Ft:
Number of Chimneys
Number of Hearths
Additional Features
Heating System
None
Electric
Gas
Oil
Propane
Solar
Other
Central A/C
No
Yes
Central Vacuum
No
Yes
Security System
None
Monitored
Unmonitored
If the home is over 30 years old, have the following been updated?
Electrical:
No
Yes
Plumbing:
No
Yes
Heating:
No
Yes
Additional Comments
Please provide any additional comments below:
Created by:
Design Team NY
