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29 – 50 Union St. 2Fl. Flushing. NY 11354 (Headquarter) TEL +1 718 461 8300 Fax 718 461 8185

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Name First name Middle name Last name

Address of Property to be insured Street City State Zip Code Phone Number Fax Number (Optional) Email

Property Information Square Footage Dwelling Value($) Year Built Number of families Construction Type Roof Type

Fire and Theft Information Over 1000 feet from a fire hydrant? Distance to nearest fire station Type of fire alarm Type of theft alarm

Requested Coverages Liability coverage Medical payments Policy deductible

Policy Information Have you filed a previous homeowners claim? Date of last claim Current policy with Current policy expires