Classic Coverage Insurance Agency ~ 631 422 8585 ~ fax 631 422-8586
Home Information
Full Name
Address
City State Zip Code
If outside city limits, name of responding Fire Department. Miles to Dept Feet to Hydrant
Social Security # of owner(s)
Square Footage
# of Stories
Owner-occupied or Rented to others
1 2 3 4+ Person Family
Dwelling Co/op Home Own a condo
Construction Type:
Frame Brick Over Frame Solid Masonry Other (specify)
Home Extras *
Year Built
Smoke Detectors Yes No
Central Station Burglar Yes No
Dead Bolts Yes No
Central Station Fire Yes No
Fire Extinguisher Yes No
Have any of the following systems been updated in last 20 years? *
Roof Yes No
Plumbing Yes No
Heating Yes No
Electrical Yes No
Type of heat?
If oil, where is tank stored? Underground Above Ground Basement
Electrical system protected by circuit breakers? * Yes No
Do you need special coverage for Jewelry, Furs, Cameras, Fine Arts, etc?* Yes No
If yes, describe item and value:
Have you had any losses to your home or property in the past 3 years? * Yes No
If yes, describe (include date of loss):
Do you own a Swimming Pool? * Yes No
If yes, type (IE. Aboveground or Underground):
Fenced in (y/n) Diving Board/Slide
Do you have a Wood Stove or Fireplace? * Yes No How many?
Do you own any Animals or Exotic Pets? * Yes No
If yes, type (IE. Dog, Cat, Bird, House, Other):
Breed:
Do you own or rent any other property? * Yes No
Do you conduct any business out of the home? * Yes No
Other Information
Current Insurance Company Current Policy Expires* Current Premium
If Renting: Number of apartments in your building
Dwelling or Building Coverage Limit $
Value of Personal Property or Contents
Deductible $250 $500 $1,000
Medical Payment $1,000 $5,000
Personal Liability Limit $100,000 $300,000 $500,000 $1,000,000
Fair Credit Reporting Act Notice: We are required to inform you that as part of our underwriting procedure, a consumer report may
be requested. Additionally, subsequent consumer reports may be requested on renewal or as an update on your insurance
application. Upon your written request, you will be informed whether or not a consumer report was requested, and if so, the name
and address of the consumer
Reporting agency to whom the request was made.
This website is not an offer to sell, but to help gather information in order to offer insurance quotes
Home Information
Full Name
Address
City State Zip Code
If outside city limits, name of responding Fire Department. Miles to Dept Feet to Hydrant
Social Security # of owner(s)
Square Footage
# of Stories
Owner-occupied or Rented to others
1 2 3 4+ Person Family
Dwelling Co/op Home Own a condo
Construction Type:
Frame Brick Over Frame Solid Masonry Other (specify)
Home Extras *
Year Built
Smoke Detectors Yes No
Central Station Burglar Yes No
Dead Bolts Yes No
Central Station Fire Yes No
Fire Extinguisher Yes No
Have any of the following systems been updated in last 20 years? *
Roof Yes No
Plumbing Yes No
Heating Yes No
Electrical Yes No
Type of heat?
If oil, where is tank stored? Underground Above Ground Basement
Electrical system protected by circuit breakers? * Yes No
Do you need special coverage for Jewelry, Furs, Cameras, Fine Arts, etc?* Yes No
If yes, describe item and value:
Have you had any losses to your home or property in the past 3 years? * Yes No
If yes, describe (include date of loss):
Do you own a Swimming Pool? * Yes No
If yes, type (IE. Aboveground or Underground):
Fenced in (y/n) Diving Board/Slide
Do you have a Wood Stove or Fireplace? * Yes No How many?
Do you own any Animals or Exotic Pets? * Yes No
If yes, type (IE. Dog, Cat, Bird, House, Other):
Breed:
Do you own or rent any other property? * Yes No
Do you conduct any business out of the home? * Yes No
Other Information
Current Insurance Company Current Policy Expires* Current Premium
If Renting: Number of apartments in your building
Dwelling or Building Coverage Limit $
Value of Personal Property or Contents
Deductible $250 $500 $1,000
Medical Payment $1,000 $5,000
Personal Liability Limit $100,000 $300,000 $500,000 $1,000,000
Fair Credit Reporting Act Notice: We are required to inform you that as part of our underwriting procedure, a consumer report may
be requested. Additionally, subsequent consumer reports may be requested on renewal or as an update on your insurance
application. Upon your written request, you will be informed whether or not a consumer report was requested, and if so, the name
and address of the consumer
Reporting agency to whom the request was made.
This website is not an offer to sell, but to help gather information in order to offer insurance quotes
Classic Coverage
~ 631 422 8585 ~ fax 631 422-8586
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