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78 Montauk Hwy, Suite 4
East Moriches, NY 11940
(877) SAY-NYIK Toll Free
(877) 729-6945
(631) 874-6440 Long Island
(631) 874-6446 Fax

Home Owners Insurance

PLEASE COMPLETE THIS FORM *Required Fields
Name*
Driver's License*
Date of Birth*
Address*
City*
State/Province*
Zip Code*
Email Address*
Phone*
Best Time to Call
How Long at Current Address
If Less than 3 Years Prior Address
How did you hear about us?	OTHER

Spouse/Partner
Name
Driver's License
Date of Birth

Current Insurance
Company
Policy #
Expiration Date

Property Information
# Occupants
Address (If Different from Above)
City
State/Province
Zip Code
Year Built
If Completely Renovated What Year

Current Coverage
Dwelling	$
Contents	$
Liability	$
Deductible	$
Water Backup	Yes
Building Information
Style
Type of Heat	Location Underground Tank? Yes
# Floors
# Bedrooms
# Baths
# Garages
Basement?	Yes
Central A/C?	Yes
Fireplace?	Yes
Pool?	Yes
Trampoline?	Yes
Alarm?	Yes Central Station Police & Fire? Yes
Dog?	Yes Breed
Primary Residence?	Yes
Other Structures

*Press submit when you are done.*