631ContractorsInsurance.com
Home Owners Insurance Quote Fax Form
Please fill print and fill out this form and
fax to 866-542-6687 ext 467

Your Personal Data:
 
Your Name: _________________________________________
Property Address: _________________________________________
City: _________________________________________
State: New York
Zip/Postal: _____________________
E-Mail (REQUIRED): ______________________________________
Phone: ______________________________________
Fax (optional): ______________________________________
 
Dwelling Information
 
Year Home Built: _____________________
Home Square footage: _____________________
 
Is this Builder's Risk?
(new home constr.) 		NO YES
 
Month/Year home
to be complete: 		_________________________
 
Number of units: 1 family Duplex
 
 
Type foundation: Slab Crawlspace over slab
Basement Other (list in remarks)
 
Type Roof: Shingle Wood Shake
Tar/Gravel Metal
Metal Other
 
Number of stories: One 1.5
Two Three
 
Do you own animals or pets? Yes No
If yes, list type/for dogs, list breed: ________________________________________
 
Deck Yes No
 
# of feet to nearest
fire hydrant: 		# of miles to nearest
fire station: ________________
 
Heating? Gas Oil
 Propane Other
 
Basement Yes No Finished
 
Central Air Yes No
 
Fire Alarm Yes No
 
Smoke Detectors Yes No
 
Plumbing type: Copper Galvanized
Mixed (Copper/Galvanized)
PVC
 
Circuit Breakers or fuses? Breakers Fuses
Currently Insured? Yes No
 
How is Your Credit History?
(Some carriers use credit history to qualify)		 _______________________________________
 
Prior Claims? Yes No
Describe claims in detail: _________________________________________

# Bedrooms: _____________ # Bathrooms: ______
 
# Fireplaces: ____________ # Chimneys: ______
 
Special features
(i.e., deck, air conditioning, alarm systems, pool, etc.)		 ________________________
 
Coverages:
 
Dwelling Cov. $ ________________ Contents $ _________
Liability Cov. $ _______________ Deductible $
($250, $500, $1,000, etc.)		 _________
 
Comments/Remarks
(describe any scheduled jewelry, in-home business, or other special coverages needed here): 		___________________________
 
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