John J. Grimaldi & Associates, Inc.

Homeowner Quote Request

This application process will allow you to request a quote for homeowner's insurance.

This is some information you should have available to complete the application:

   1) Zip Code of the insured home
   2) Value of the home
   3) The year that the home was built

Personal Information

Name:

Mailing Address:

City, State:

Phone:

Email:

SSN:

Referrer's Name:

Property Location

Address:

City, State, ZIP:

, NY

County:

Current Coverage's

Dwelling:

Liability:

Other Structures:

Medical Payments:

Personal Property:

Loss of Use:

Desired Coverage's

Deductible Desired:

Year Constructed:

Number of Family:

Construction Type:

Questions

Any other structures (garage, storage building, residence etc.) on premises?	Yes No
Any insurance declined/canceled or non-renewed in the last three years?	Yes No
Are there any other type of heating devices used other than central?	Yes No
Do you have any other insurance with this company?	Yes No
Swimming pool on premises?	Yes No Fenced In Ground Above Ground
Any animals on premises?	YesNo Number and Breed:
Wiring: Year of last update?	Circuit Breakers Fuses
Plumbing: Year of last update?	Copper Pipe PVC
Roof: Year of last update?	Shingle Rubber Metal Rolled Roof (Tarpaper)
Heating: Year of last update?	Cleaned/maintained at least once per year? YesNo
Any claims in the last five (5) years?	YesNo
Who is the responding Fire Department
Is the home a townhouse?	Yes No
Are there any smoke alarms in the home?	Yes No
Do you own any recreational vehicles, such as a snowmobile or a boat?	Yes No

Additional Comments

John J. Grimaldi & Associates, Inc.
137 Summer Street • Buffalo, NY • 14222 • 716-636-1355 • 1-800-500-1355 • Fax: 716-636-1350