New York Insurance by Bermack, Champion & Lewine for Auto, Homeowners, Business and Personal Insurance
This website offers services primarily to current and future residents of NY, CT and NJ.
14 Penn Plaza, Suite 1611, New York NY 10122 • Telephone: 212-239-1140
 
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Homeowners Quote
This Quote is for NY, CT and NJ only
Fill out the form below to obtain a customized homeowners quote. To obtain an accurate quote, please be as complete as possible.
Applicant Information
Name:
Street Address:
City/State/Zip: / /
Home Phone:
Work Phone:
Email:
Coverage Selections
Personal Property Limit:
Liability Coverage Limit:
Medical Payments to Others:
Deductible:
Off Premises Theft Coverage:
Replacement Cost Contents:
Replacement Cost Dwelling:
Loss Assessment Coverage
(for Condominium/Coop owners):
Building Additions and Alterations Coverage:
Property Information
Property
Address:
Street :
City/State/Zip: / /
Construction Type:
Year Built: "yyyy"
Square Footage: sq. ft.
# Rooms:
# Apartments:
Market Value: $
Replacement Cost: $
Structure Type:
# Families
# Household Residents:
Live-Ins
(ex. housekeeper, babysitter):
yes/no
Is any resident a smoker?:
Purchase Date: "mm/dd/yyyy"
Purchase Price: $
Distance to Hydrant: ft.
Distance to Fire Station: mi.
Wired Alarm Systems
(connections to fire/police authorities):
Fire Alarm?: yes/no
Burglar Alarm?: yes/no
Fuel: Gas

Oil


If "Oil" is checked, "Storage Tank Location" below is required.

Storage Tank Location
(ex. "basement"):
Electric
Wood
Coal
Solar
Please enter Year of Renovation, if applicable, for the items at right. Electrical: yyyy
Plumbing: yyyy
Heating: yyyy
Roof: yyyy
Exterior Painted: yyyy
Occupied By:
Please check those which apply: Deadbolt
Smoke Detector
Fire Extinguisher
Property Visible to Neighbors
Sprinklers
Gated Community
24 Hour Doorman
Security Cameras
Swimming Pool?: No
Yes Approved Fence
Diving Board
Above Ground
In-Ground
Roof Type: ex. "shingle"
General Information
Please check those which apply.
At Home Business:      Description:
Hazard present for flooding, brush fire, forest fire, landslide:      Description:
Animals/Pets: Description/Breeds:
Property located within 2 miles of tidal water:      Description:
Property located on more than 5 acres:      Description:
Trampoline on Premises: Yes
No
Rooms, Attics and Garages
Please enter the quantity of each type of unit in your home.
Kitchen
Dining Room
Living Room
Den/Study/Office
Family/Recreation Room
Bedroom(s)
Bathrooms(s)
Large Utility/Laundry/Sewing Rooms (Over 150 sq. ft.)
Finished Basement (Omit if counted as family/rec room)
Attached 2-Car Garage
Large Finished Attic (Over 150 sq. ft.)
Partially Finished Attic
Partially Finished Basement
Brick/Stone Exterior Walls
Central A/C
Aluminum/Vinyl Siding
Large Wall Fireplace
Enclosed Porch/Breezeway
Clay Tile or Slate Roof
Any Other Unit Not Listed Here
 
Half Bath
Large Open Porch/Breezeway
Standard Fireplace
Unfinished Basement
Attached 1-Car Garage
Built-in 2-Car Garage/Carport
Small Utility/Laundry Sewing Rooms (Under 150 sq. ft.)
Foyer/Entrance Hall
Dressing Room/Walk-in Closet
Unfinished Attic
Small Finished Attic (Less than 150 sq. ft.)
Mudroom (With separate entrance)
Brick/Stone Veneer (Front Wall)
Dinette or Partitioned Breakfast Nook
Any Other Unit Not Listed Here
Thank You!
You've completed the form. If you have any general questions or comments, please enter them in the box below, then click the submit button. Thank you for considering Bermack, Champion & Lewine. We will respond to you promptly.
General Questions/Comments:


     


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