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Agent!

 
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andsiegel.com

 

Toll-Free: 1-866-669-0365
Phone: 1-631-669-0365
Fax: 1-631-669-0158

Contact Address:
Norton & Siegel, Inc.
PO Box 220
Babylon, NY 11702

"Remember, All Our Policies Come With an Agent!"
 
On-Line Flood
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!


Your Name:
Property Address:
City:
State: (Must be New York)
Zip/Postal:
E-Mail (REQUIRED):
E-Mail (again for accuracy):
Phone:
Fax (optional):
 
Dwelling Information
Year Home Built:
Was the building substantially improved
(more than 50% increase in market value)
at one time? If so, what year?
 
Is home currently under construction? No Yes
 
Home Square footage:
 
Number of units: 1 family Duplex
3 Family 4 Family
 
Type foundation: Slab at Ground Level
Basement, Finished
Basement, Unfinished
Elevated with enclosure
Elevated without enclosure
 
Type Roof: Shingle
Wood Shake
Tar/Gravel
Spanish Tile
 
Number of stories: One 1.5
Two Three
 
If more than 1 story, are some
contents on ground floor, or contents
ONLY above the first floor?
On ground floor
Above first floor only
 
Does home have a garage? Yes No
If yes to Garage, please describe if detached or attached, and if it containts any equipment such as washer/dryer, heating & air, etc.
 
Currently Insured? Yes No
Name of Carrier & how long insured?
 
Do You Have an Elevation Certificate? Yes No
 
Prior Claims? Yes No
Describe claims in detail:
 

Coverages:
Dwelling Cov. $ Contents $
  
Deductible:     $ $1000 $2000
 
Comments/Remarks:
 
Send my quotation via: E-Mail Fax
Regular Mail


Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release them from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me a Quote NOW!



Norton & Siegel, Inc. | PO Box 220 | Babylon, NY 11702 | Phone: 1-631-669-0365 | Fax: 1-631-669-0158
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