Homeowner's Insurance
*Required Fields
Insured's Information
First Name
*
Last Name
*
Address 1
*
Address 2
City
*
State
*
Zip
*
Phone
*
-
-
Email
Occupation
Birth Date
*
January
February
March
April
May
June
July
August
September
October
November
December
/
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
Social Security Number
-
-
How Long at Current Address?
*
years
If Less than three Years
(previous Address)
Dwelling Information
Dwelling Type
*
Condo
Co-op
Apt
Single Family
Two Family
Three Family
# of Stories
Dwelling Use
*
Primary
Secondary
Rental
Purchase Price
*
$
.
Year Built
*
Construction Type
*
Brick Veneer
Fire Resistive
Frame
Brick Masonry
Aluminum/Vinyl
Type of roof
*
Heating
*
Oil
Gas
Electric
Oil Tank Location
*
In Ground
Above Ground
Interior Walls & Ceiling
*
%
Drywall
%
Plaster
%
Painted
%
Paneled
%
Tiled
Floors
*
%
Hardwood
%
Parkae
%
Carpeted
%
Tiled
Year Renovated
*
Wire
Plumbing
Heat
Roof
Number of Rooms
*
Bathrooms:
Full
Half
Bedrooms
Kitchens
Basement
Sq. ft.
None
Finished
Unfinished
Walkout
Garage
No. of Cars
None
Attached
Detached
Not Applicable
Brick
Frame
Attic
Sq. ft.
None
Finished
Unfinished
Walkout
Fireplaces
How Many?
None
Built In
Pre Fab
Porch
Sq. Ft.
None
Front
Back
Both
Not Applicable
Open
Closed
Alarms
Burgarlar
Fire
Sprinkler System
Dead Bolt
Smoke Alarm
Central Air
*
Yes
No
Separate Ducts from Heat?
Yes
No
Animals
*
Yes
No
What Kind
Do You Smoke?
*
Yes
No
Do You Have a Mortgage?
*
Yes
No
Mortgagee
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January 22, 2011
9AM
LOCATION:
75 S. Broadway
4th Floor
White Plains, NY
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Higinio Agency
75 S. Broadway | White Plains, NY | 10601
Call us TODAY 914.304.4222
info@HiginioAgency.com