Homeowners Insurance Quotation Form
To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you.
 
Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.
 
(As part of our underwriting procedures, we order consumer reports relating to credit, driving record and loss history as allowed by law.  Upon your request, we will advise you of the name and address of the consumer reporting agency from whom we obtain such reports.)

Personal Information

Your name
First: 		  Last:  
 Social Security #  

Date of birth:

  
Spouse's Name
First:		   Last:  
Social Security #:  

Date of birth:

  
Address:  
City:   State:        Zip code: 
  E-mail:  
Phone numbers     (daytime)     Fax:
      (evening)

     How many years have you lived at the above address?  

     If less than 2 years please supply your previous address:  
  How would you prefer to be contacted regarding your quote?    

Phone      Fax      Mail     E-mail

                          If by phone, best time to call is:  AM   /  PM
Employer:  
Occupation:

Structural Information
  Year home built:          Total sq. footage of living area:    (if known)        Construction:
  Primary residence?Yes No                                      What part of the year is the home occupied? 
  Number of families living in the home:                                     If condo/co-op, how many units in building? 
  Do you own any other homes?  Yes No  
  Is business conducted on the premises?              Yes No               
  Any special interests or hobbies that could be considered a home based business?   Yes No
  Does anyone in your home smoke?                      Yes No
  Experienced any loss or claims in the last 5 yrs? Yes No
  Heating system:        If Oil, where is oil tank?

Do you have the following in your home:
            Burglar alarm? 
          Deadbolt locks? Yes  No		                         Swimming pool? Yes  No  
                               Trampoline? Yes No
  Unusual/exotic pets? Yes  No          
                  Livestock? Yes   No 
                           Dog? Yes   No 
                                      Breed?        
                                      Any aggressive behavior?Yes No  		                     Smoke detectors? Yes   No 
                    Fire extinguishers? Yes No
                                 Fire alarm? 
          Interior Sprinkler system?  

 
  Kerosene, wood or oil stove?  Yes  No               Professionally Installed?  Yes No
   If you have any furs or jewelry,   please specify the approximate total value:   $

Is your home located
 Within 1000 ft from a fire hydrant? Yes No Within 5 miles from a fire station? Yes   No
Close to a body of water or susceptible to flooding? Yes No On a hillside? Yes No
Gated community Yes No  24 hour security guard?: Yes No

Current coverages and deductibles:
Dwelling (Coverage A - Replacement cost of your home) $:  Other structure $:
If Condo/Co-op:  Value of improvements and betterments $:  Loss of use of your home $:
 Personal property/ contents $: Medical  payments $: 
Personal liability $:  Hurricane Deductible $:
Deductible $:    

Additional  questions:

Do you have/want backup of sewers and drain coverage?   Yes No
 
    Updating:  If your house is over 15 years old:    Age of Roof                     
                                                                                 Do you have circuit breakers? Yes No
                                                                                                  All Plumbing copper? Yes No
                                                                                                      All wiring copper? Yes No
     
 

   761 Koehler Avenue, Ronkonkoma, NY  11779                                                                              ©2006 Irving Weber Associates, Inc.