marquis brokerage .:. home
about us
homeowners insurance
auto insurance
insurance applications
contact us
Homeowners Application
Download Application
Complete Application Online
Renters Application
Complete Application Online
Co-op/Condo Application
Complete Application Online
Automobile Application
Download Application
Complete Application Online
Credit Form
Download Application
Complete Application Online
Get Adobe Reader

Marquis Brokerage
All Forms of Insurance

11 Broadway Suite #440
New York, NY 10004

Toll Free: (800) 711-4911
Local: (212) 825-0055
Fax Number: (646) 807-4765
 
Homeowners Insurance Application

Personal Information
Last Name

First Name

Name of insured (if different from above)

Social Security Number
 
-
   
-
  
Date of Birth
 
/
   
/
  
Home #
(
   
)
    
-
  
Work #
(
   
)
    
-
  
Fax #
(
   
)
    
-
  
Email Address

Property Information
Address of Property(s) to be insured

Year of construction

Approximate value of dwelling

Amount of insurance requested

Umbrella policy desired?
Yes   No
Primary   Secondary Location
House
Attached   Detached   Semi Attached
1 family   2 family   3 family   Other
Including Off Premises Theft   Excluding Off Premises Theft
Heat
Gas   Oil     Updated years ago
Electric
220   Other
Plumbing
Copper   Other
Roof Type
Asphalt   Rubber   Other
Roof Pitch
Flat   Pitched
Pool
Yes   No
Pool Type
In Ground   Above Ground
Garage
Attached   Detached   None
Attic
Finished   Unfinished   None
Basement
Finished   Unfinished   None
Building Type
Masonry/Brick   Wood/Frame
Alarm
Central   Fire   Police   Local
Number of Bedrooms
Number of Kitchens
Number of Full Bathrooms
Number of Half Bathrooms
Number of Dining Rooms
Number of Living Rooms
Number of Laundry Rooms
Number of Dens
Porch
Deck
Terrace/Balcony
Central Air
Number of Fireplaces
Wood Burning Stove
Total Square Footage

Is the house near any water?
Yes   No
Any Claims?
Yes   No     Closing Date
Prior Insurance Carrier

Miles to the Fire Dept
Feet from a fire hydrant
Fire Dept
Paid   Volunteer
Desired property deductible
$500   $1000   Other
Liability
$100,000   $300,000   $500,000   $1,000,000
Medical payments to others
$1000   $5000   Other
Owner Occupied   Tenant Occupied

Other
Items also needed to be insured
(ie. Boat, Jet Ski, Wave Runner, etc.)

Scheduled Items
Items you wish to cover for the full amount of their value, which may be excluded or items not covered for their full value
(include dollar values for all scheduled items)
Jewelry $     Furs $     Silverware $
Fine arts $     Cameras $     Firearms $
Antiques $     Musical Instruments $
Fine China $     Crystal $     Bikes $
Copyright 2003 Marquis Brokerage | All Rights Reserved.
An ITS Production