New Era Insurance Brokerage
197-02 Hillside Ave, NY 11423, USA
info@neib.us
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+1 917-791-5767
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Property
Insurance Form
Please complete the form below to receive a rapid quote.
"
*
" indicates required fields
Step
1
of
4
25%
Property Information
Address of Property
*
# of Apt/Units
*
Does the property have any commercial space?
*
Yes
No
New Purchase ?
Yes
No
Closing Date
MM slash DD slash YYYY
Building Coverage Amount Preferred
Property Owner:
Name
Phone Number
*
Email
*
Date of Birth
MM slash DD slash YYYY
Social Security Number (If provided, will help get a cheaper quote if good history)
Is the property owner a company or individual(s)?
*
Company
Individual (s)
Tax ID
Business Income Coverage Amount Preferred
# of commercial units
Type of business
*
Is at least one Unit/Apt occupied by the Owner?
Yes
No
Address of Owner Property
Do you have a mortgage or applying for a mortgage?
Yes
No
Outstanding Loan Amount
Loan Number
Mortgagee Name required for loan purposes
Heat is
Oil
Gas
Do you have a Pool?
Yes
No
Is the pool
Fenced
Non Fenced
Other
Any additional information you would like to provide?
Additional Questions that can help Reduce Price
Provide estimated date of when the following was last updated
Wiring/Electrical
MM slash DD slash YYYY
Plumbing
MM slash DD slash YYYY
Roof
MM slash DD slash YYYY
Heating
MM slash DD slash YYYY
Do you have Burglar Alarm?
Yes
No
(Attach Proof)
Accepted file types: jpg, gif, png, pdf, doc, docx, xls, xlsx, Max. file size: 10 MB.
Do you have a Fire Alarm?
Yes
No
(Attach Proof)
Accepted file types: jpg, gif, png, pdf, doc, docx, xls, xlsx, Max. file size: 10 MB.
Any other Proof?
Yes
No
(Please Attach)
Accepted file types: jpg, gif, png, pdf, doc, docx, xls, xlsx, Max. file size: 10 MB.
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