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Please fill
out the Hosue Insurance Quote Request Form below and our
professional local Insurance Agent will get back to you as
soon as possible: |
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*Disclaimer: The insurance agency will obtain a consumer credit
report at the time of application and may also do so for
renewals and extensions. At your request, the insurance agent
will tell you the name and address of the consumer reporting
agency that provided the information. You agree that the
information given by you is true and is not misleading and the
insurance agent will keep this application and supporting
information on a confidential basis. Rates and terms may vary
depending on your credit worthiness. The Long Island Browser
(www.LongIslandBrowser.com)
is not responsible for the processing of your request. A third
party provider will contact you with regards to your specific
circumstances. |
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| Name: |
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Address: |
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| City: |
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State: |
New
York State Only |
| Zip: |
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Phone: |
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| Fax: |
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E-mail: |
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| Date
of Birth: |
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Social Security #: |
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Name
of current insurance co.
& policy #: |
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What
amount is house currently
insured for? |
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| Age
of house: |
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| No.
of families: |
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| No.
of stories: |
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| Is
house brick or frame? |
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| Sq.ft.
of ground floor: |
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| No.
of baths: |
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| Does
house have air-conditioning? |
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If
yes, is air conditioner built
in wall or in window? |
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| Does
house have a porch? |
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| What
type of basement? |
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