Hometown Agency
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Hometown Agency

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632 Union Boulevard
West Islip, New York 11795
Phone (631) 669-6200
Fax (631) 669-2349

Hometown Agency
Hometown Agency

Our commitment is to serve you with the highest degree of professionalism.  You can expect our associates to utilize their extensive knowledge and experience to act as your personal insurance advisors.  Our formula for success is quite simple - We work for you.

 Hometown Agency
Hometown Agency

Thank you for your trust in us,

Dan Weber, President

  
Hometown Agency

 

Home Owner Insurance Quote

First & Last Name:
Street Address: 
City, State & Zip: 
,  
E-Mail Address: 
Telephone:
Fax:  
Your occupation:
Date of Birth:  

 
Current Insurance Information
Insurance Company Name:
Policy Exp. Date:
Amount Insured for:
Mortgage Amt:
Premium Amt:
Term:
Any Claims in Last 3 years?

 
General Information About Home:
Year home built in:
Total Square Feet:
Yrs at present address:
Liability coverage:  
Market Value:
Distance to nearest fire hydrant:  
Distance to nearest fire department:  
Home Type:
Home Construction:
Roof Type:
Garage Type:
Age of roof:
Garage:
No. of Bedrooms:
No. of Fireplaces:
No. of Bathrooms:
Exterior:

 
Additional Information
Swimming Pool?:  
Pool Fenced:  
Diving Board:  
Trampoline:  
Smoke Detector:  
Security System:  
Heating System:  
Fire Alarm:  
Replacement cost of personal items:
Any business conducted in home:
List values of any jewelry,
furs, or speciality items:
List pets &
breeds:
Do you want to include Flood Insurance?:

 
Additional Comments
Please give any additional comments you may have or enter any information that did not have enough room for:


 

 

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