Parsons & Associates, Inc. -- Homeowners Proposal Form

Parsons & Associates. Inc. -- Insurance & Risk Management

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Homeowners Insurance Proposal Form
For the fastest and most accurate homeowners insurance proposal, please provide as much information possible in the form below. This information will be kept confidential and will be used for proposal purposes ONLY!

This Online Application is on a Secure Server. Click on the seal on the left for more information on the certificate's authentication. Privacy Statement: Any information provided by a consumer or customer via our online forms WILL be held in the strictest confidence. No information will be shared with others. Our goal is to respond to all submissions within two business days.

	Attention Netscape Communicator* users:*
This form best viewed with a 12 point font setting

We only accept inquiries for insurance written in New York State

General Information

Name:

Address:

City: State: ZIP:

County: Email:

Phone Day: ( ) - Night: ( ) -

Best time to call: am pm

Occupation: How long at current job: years months

Soc. Sec. #*: Date of Birth:

*Please Note: In order to provide you the most accurate policy quote, some of the companies we represent may require a credit and/or claims history which require your Social Security Number. You do not have to provide social security numbers at this time, however we cannot guarantee that we can provide you the most accurate quotation until we secure your credit information. We will not share this infomation with any other entity other that prospective insurance companies that will assist us in preparing your quote. All information on this form will be strictly used for internal purposes only

Current Homeowners Insurance Company (not agency):

Company Name:

Policy Exp. Date: / /

Amount Insured For: $

Premium: $

Term: 6 Months 1 Year Other

Home Information

How long at present address: years months # of claims in last 3 years:

Sq. footage of home (excluding
garage and basement): Year home was built:

Structure Information

Type: Construction: Roof: Foundation: Garage:

Age of roof: yrs.

Features

Bathrooms: Basement: Deck/Porch/Patio: Fireplaces:

# of Full:
# of Half:
Sq. Ft: Deck Sq. Ft:
Porch Sq. Ft:
Screened Patio Sq. Ft: # of Chimneys:
# of Hearths:

Additional Features

Heating System: Central Air: Central Vac: Security Alarm: Fire Alarm: Smoke Detector:

yes
no yes
no yes
no

Additional Comments:

Please give any additional comments about the coverage you desire:

Thank you for your time in submitting this homeowners Proposal form. One of our representatives will respond to your submission as soon as possible!