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(631) 207-5400



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Renters Insurance Quote

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General Information
Full Name:  
Day Telephone:  
Street Address:  
Eve Telephone:  
City, State & Zip:  
Fax:  
E-Mail Address:  
Your occupation:  
Best Time To Reach You:
 
Date of Birth:

Current Insurance Information
Insurance Company Name:  
(NOT Insurance Agency/Broker) 
Policy Exp. Date:  
Contents Insured for:
Current Ded:  
Premium Amt:  
 
Policy Term:

Condominium Information
Will you or do you live on this property:
Yes No
How much coverage do you want on your personal property:
$
How much personal liability:
$100,000 $300,000
$500,000 $1,000,000
Deductible:
$500 $1,000 $2,500
Number of Units:
Number of Stories:
Is there a 24-hour door man:
Yes No
Are there elevators:
Yes No
Year Built:
(yyyy)
Approximate Square Feet:
Have you reported any claims or losses to your insurance company within the last 5 years
Yes No
Type of Construction:
Brick Wood frame
Cinder block Other
Roof Type:
Composite shingle Tile
Wood shingle Other
Roof Age:
Years (if unknown, please indicate)
Burglar Alarm:
Yes No
Heating System:
Forced air Electric Boiler
Oil Propane
Number of gas or wood fireplaces or stoves:
What floor do you live on:
Number of bathrooms:

Additional Information
Any business conducted in home:  (if Yes, please describe)
Yes No
List values of any jewelry, furs, or specialty items:  
List pets & breeds:  

Additional Comments
Please give any additional comments or questions

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