Homeowners Insurance Quotation

The information submitted via this form is confidential.  If you have a policy currently, the information necessary to complete this form may be found on the first few pages of your policy.

Fill in this form as completely as possible to ensure an accurate QUOTE. If you DO NOT KNOW the correct answer to any of the REQUIRED INFORMATION, skip them, but note in the comments section what you were unsure about.
INFORMATON ABOUT YOU
Name
Address
Evening Phone
Fax

Daytime Phone

Email
Date of Birth
Social Security Number
Best Time to call

ABOUT THE PROPERTY
Why do you require Homeowners Insurance
Occupancy
Number of families occupying home
When was the home built
If Home is >30 Yrs. Old, please provide replacement/update information
Roof Last Replaced
Electrical System
How many amps
   
Circuit breakers (Yes/No)
Oil Burner / Gas Burner
 Oil Gas
Construction of Home
Style of Home
Number of stories (excluding basement)

Approx square footage OF FIRST FLOOR
Type of Foundation
Type of Heating
Garage Type
# cars garage holds

 

ABOUT YOUR MORTGAGE
Name and Address of Lender
Loan Number
Loss Payee
 check if yes
Additional Insured

check if yes
Mortgage Fee

 

 

SECURITY FEATURES
Security Features (check all that apply)
  
Smoke Detectors
Fire Extinguishers
Local Fire Alarm
Local Burglar Alarm
Central Station Fire Alarm
Central Station Burglar Alarm
Dead bolts
   

 

PROPERTY DETAILS
Central Air
Fireplace
Number of full bathrooms
Number of bedrooms
Swimming pool INGROUND?
   

 

EXISTING INSURANCE
Current Insurance Company
POLICY NUMBER
Policy Exp date
# of claims in last 5 years (note later)
Claim details
   

 

POLICY DETAILS
Purchase Price
Date of Purchase
Market Value Replacement Cost

Current Coverages

  
Dwelling

Personal Property
Personal Liability
Building Deductable
Ever filed for bankruptcy
Credit Rating
Comments
GCS Mortgage, Inc. 31 East 32nd Street, 4th Floor New York, NY 10016 Tele: 212 545-9201 Fax: 212 447-4890 E-Mail: info@gcsmortgage.com