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Homeowners: NY State

  • Must be owner occupied 1 family only
  • Forms ML-1, 2, 3, 4 & 8
  • All policies written for 3 year term, rates guaranteed
  • Clear unprotected properties with Home Office Underwriter
  • Inland Marine schedules available
  • Up to $4000/Item (Bill of sale or Certified Gemologist appraisal)
  • Swimming pools and acceptable dogs
  • $100,000 maximum liability
Referral Source:

If Policy Holder
   Name:
   Account:
Agent Assigned:

Full Name:

Multi-Policy? Yes No
Coverage Type:

Address
   Address 1:
   Address 2:
   City:
   State:
   Zip:
Phone:

Alternate Phone:

Date of Birth:

Soc Sec #:


Spouse
(if any)
   Name:
   Date of Birth:
   Soc Sec #:

Property Info
   Purchase Price:
   Mortgage Amount:
   Year Built:
   Multi-Family: Yes No
      If yes, how many:
   Style:

   Sq Footage:
   Const. Type: Brick Frame
   Quality:

   # of Stories:
   Bathrooms:
   Total Rooms:
   Basement: Yes No
      % Finished:

   Central Air: Yes No
   Fireplace: Yes No
   Smoke Alarms: Yes No
   Fire Extinq: Yes No
   Dead Bolts: Yes No
   Burglar Alarm:

   Garage:

   Dog: Yes No
   Pool: Yes No
   Deck: Yes No
   Shed: Yes No

Prior Address
(if different)
   Address 1:
   Address 2:
   City:
   State:
   Zip:

Prior Insurance
(if any)
   Company:
   Years With:
   Policy #:
   Prior Claims:

Need For Insurance
   Closing (when?):
   Policy Renewal:

Mortgagee
   Name:
   Address 1:
   Address 2:
   City:
   County:
   State:
   Zip:
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