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Auto Insurance AUTO

Auto insurance protects you against financial loss if you have an accident.

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Homeowners Insurance HOME

A standard policy insures the home itself and the things you keep in it.

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Umbrella Insurance UMBRELLA

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Home > Homeowners > Homeowners Quote Request Form
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Homeowners Quote Request Form


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information
First Name *
Last Name *
Street *
City *
State *
ZIP / Postal Code *
Primary Phone Number *
E-Mail Address *
Date of Birth *
Social Security Number
Is there a Co-applicant? If so, please provide name, date of birth, and occupation
Is this home a new purchase? *
If yes, please provide current/prior address
Year built *
Square footage (excluding attached garage) *
Contruction type *
Number of Floors including basement *
Burglar Alarm? *
Fire Alarm? *
If Yes, Is it a Central Station or Local?
Any steps going up to your front door? *
If yes, how many?
Is there a railing? *
What type of siding does your home have? *
Do you have any pets or exotic animals? If so, please list species & breed. *
Do you have a swimming pool? *
If yes, is the pool above ground or in ground?
Diving Board?

Slide?

Is the backyard fenced with a self-locking gate? *
What type of heat does the house have? *
If oil heat, where is the oil tank located?
Is any portion of the roof flat? *
When was the last time the roof was redone? *
When was the last update for the heating system? *
When was the last update for the electric? *
When was the last time the plumbing was upgraded? *
What type of basement do you have? *
Do you currently have insurance? *
If yes, please provide current carrier's name & expiration date
Deductible Amount *
How much coverage is currently on the house?
Do you have a garage? *
Do you own a boat? *
If yes, please provide length & engine HP
What company is your car insurance with? (Discounts available if we have your auto insurance)
Do you carry flood insurance?
Do you own any other properties or vacant land? *
Do you have anything of exceptionally high value in the home? (Jewelry, fine arts, furs, etc.)
Any business conducted from home? *
What is your occupation? *
Do you have a sump pump in your basement?
Is there a trampoline on the premises? *
Do you have a deck? *
If yes, how many square feet roughly?
Is there a woodburning stove in the house? *
How many bathrooms are in the house? *
Mortgage name address & loan number
Loan Amount?
Who pays the premium? You or mortgage?
Do you have Life Insurance? *
How did you hear about us?
Submission Validation
Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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  • 98 Medford Ave.
  • Patchogue, NY 11772
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  • O: 631.447.2626
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