Home Owner Insurance:

ContaCT Information: Complete the following information about yourself.
Name*    
Email*    
Address*    
City    
State    
Zip Code    
Phone#*
 
Property Information: Complete the following information about your Property.
Year Built    
Dwelling Amount $    
ConstruCTion
Number of Families    
Liability Coverage    
Amount of Contents $    
Replacement Cost on Contents $    
Date of Coverage Desired
 
Room Count: Complete the following information about the number of rooms you have.
Living Rooms Bathrooms Bedrooms
Kitchens Dining Rooms Den/Study
Central AC Fireplaces Pools
Garages    
 
Additional Information: Complete the following additional information about your Property.
Losses
 
Fire/Burgler Alarm
Distance from Water
Distance from Fire Station
Nearest Fire Hydrant

Property in Excess of $1,000.00 That You Would Like to Insure
(i.e., Jewelry, Furs, Cameras, etc)

 
Name and Address of Mortgagee
 
Prior Carrier
Policy Currently in Force
Reason for Cancellation
 
Disclaimer Note: By submitting this form you understand that no coverage is bound until you receive written notice. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information for insurance quoting purposes and not distribute to other parties.

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Quick ContaCTs

72-32 Broadway suite # 402 Jackson Heights, NY 11372.

Tel: 1877-GO1-Linx
718-505-1751

E-Mail:Sales@linxinsurance.com



 
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