1000 Main Street, PO Box 70
Holbrook, New York 11741
Tel: 631-588-2116    Fax: 631-588-2147

   We Offer:

Homeowner's Insurance Quotation Request

Please fill in the information requested below.
When you are finished, click 'Submit'.
One of our representatives will contact you within 48 hours with a quotation. Thank you

Your Name and Mailing Address
City State Zip  
Phone email  
Property Information  
Property Address  
City State Zip  
What year was it built?  
Type of Construction  
How many stories?  
Do you have a pool? Yes - above ground Yes - in ground No  
Has the heating system been updated? Yes No When?  
Has the plumbing been updated? Yes No When?  
Has the electrical system been updated? Yes No When?  
Has the roof been updated? Yes No When?  
Is there a burglar alarm? Yes No  
Is there a fire alarm? Yes No  
Are the alarms monitored by a central station? Yes No  
Current Insurance Information  
What is your current insurance company?  
What is the expiration date of your policy?  
Have there been any losses or claims in the last 5 years?
Describe each loss, the date, amount paid.
Desired Coverage  
Dwelling Amount  
Other Structures Amount  
Personal Property Amount  
Loss of Use Amount  
Premises Liability Amount   
Deductable Amount  
Do you want building replacement coverage? Yes No  
Do you want contents replacement coverage? Yes No  
Where is your heating oil tank located?  
Do you have a dog? What breed and how many?

Any questions or comments?

Please note: Filling out this form will NOT cause
an insurance policy to be issued.
I understand that the insurance companies that provide a quote may review my credit history or obtain and use a credit based insurance score based on the information contained in that report. The insurance company may use a third party in connection with the development of your insurance score.