Albert Evangelista Insurance Home

Fill out our Contact form

Driving Directions

 

 

 

General Information
Name:
Address:
City:   State:    ZIP:
County:   Email:
Phone Day:  ( ) -           
Best time to call:     Morning  Afternoon
Occupation:
How long at current job:     years   months

 

Current Homeowners Policy Information:
Company Name:
Policy Exp. Date: / /
Amount Insured For: $      Premium: $
Term: 1 Year   Other  
Current Liability Limit:
Any Other Residence
Owned or Rented?
Yes   No  

                Homeowners Claims:
Date Type Amount Paid
$
$
$

 

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

Year home was built:

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

Amps:

   

Electrical System:

Distance to nearest
fire hydrant in feet:
Feet Distance to responding
fire department in miles:
Mile(s)

 

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 

 

Structure Information
Type: Construction: Roof: Foundation: Garage:

  Age of roof:   yrs.  

 

Specialty (Scheduled) Items
  Jewelry: Furs: Computers: Please fill in OTHER name (if any)

$

$

  AMOUNT   $ $ $

 

Credit History

How would you rate your credit history?   Fair    Good      Excellent 
*Please note: Credit report will be required to qualify for coverage.

 

Additional Comments:
Please give any additional comments about the coverage you desire:

 

  

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

 

 

Member of the

Patronize Your Local Businesses

Delaware  *  New Jersey  *  Pennsylvania 

Max Automotive * Max ContractorsMax Insurance *   Max Limo Network * Max Mortgages * Max Real Estate *  Max Weddings * Max Jewelers Network * Max Catering Network

www.YourLocalCounty.com   www.YourLocalNetwork.com

 

 

Powered by MAX

Website Designed by MAX