Contractors Insurance for Suffolk New York

Contractors Insurance

Suffolk, Nassau & 5 Boros of Long Island New York

www.631ContractorsInsurance.com

631- 467- 6572

Fax 631- 467-5160

	General Liability Insurance
	Auto & Truck Insurance
	Disability Insurance
	Workers Comp
	Builders Risk
	Bonds

	Home Insurance
	Auto Insurance
	Umbrella Policies
	Life Insurance
	Business Insurance
	Links
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Home Owners Insurance Quote Form

One Simple Form - takes only 2-3 Minutes to fill out online. You can also print this form here and fax it to us at 631-467-5160 or just give us a call! 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:

Are You Near Brush Area?	Yes No

# of feet to nearest fire hydrant:	# of miles to nearest fire station:


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):

Send my quotation via: E-Mail Fax
Regular Mail
Call Me By Phone

Thank you for filling out this form
Please Note: Insurance coverage cannot be bound without a written binder from our office. We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me a Quote NOW!

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General Liability l Worker's Comp l Auto & Truck l Bonds l Disability l Builder's Risk