Morris H. Bannister, Insurance Agency Peekskill NY Life Insurance Quote Request Form

 

 

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 HOMEOWNERS INSURANCE QUOTE

We would like to provide you with a free, no-obligation homeowners insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only. (* indicates required information)

Personal Information
* Name:
Address:
City:
   
State:
Zip:
Social Security:
* Day Phone:
  Night Phone:
Best Time To Call:
  AM   PM
* Email Address:
Occupation:
 Employer:
How long at current position:
Premium will be payroll deducted:  
Yes

 

Current Homeowners Insurance Information
Company Name (not agency):
Policy Expiration Date:
  Premium Amount: $
Amount Insured For:
    Policy Type: Primary Secondary
Deductible:
   

 

Home Information
How Long At Present Address:
    Year Home Was Built:
Sq. Footage (excluding garage
and basement):
sq. ft.        # of Claims In Last 3 Years:

 

Structure Information
Type
Construction
Roof
Foundation
Age of roof:
yrs.
Garage
 

 

Features
Bathrooms
Basement
Deck/Porch/Patio
Fireplaces
# of Full:
# of Half:

Sq. Ft.:
Deck Sq. Ft.:  
Porch Sq. Ft.:  
Screened Patio Sq. Ft.:  		 # of Chimneys:    
# of Hearths:    

 

Additional Information
Update Info
(Year Last Updated)
Central Air
Security Alarm
Fire Alarm
Smoke Detector
Plumbing - 19 (year)
Heating - 19 (year)
Electrical - 19 (year)
Yes
Yes

 

Coverages
Please indicate additional property that is not listed in boxes 10-14
#
Property
Amount of Ins.

#
Property
Amount of Ins.
1
Jewelry
$
8
Coins
$
2
Furs
$
9
Golfer's Equipment
$
3
Fine Arts
$
10
$
4
Cameras
$
11
$
5
Musical Instruments
$
12
$
6
Silverware
$
13
$
7
Stamps
$
14
$
Unattended Car Coverage (Stamps/Coins)
Broad Form Pair & Set Coverage
Non-Mobile Organ Coverage
Safe Credit (Identify Property, Safe Class, Etc)
ACV Loss Settlement
Replacement Cost Loss Settlement
Breakage Coverage (*On Schedule)
Blanket Coverage

Additional Rating Information

 

Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.

   


Click "Submit" to send your quote request.
One of our representatives will contact you as soon as possible.

 

 

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