Grandview Brokerage | Corporate Coverage | ◦Workers Compensation New York

Applicant

* Insured’s Name:

* DOB:

* Ssn:

Marital Status:

Spouse’s Name:

DOB:

SSN:

Any Additional Insureds on the home?:

Add Additional Insured Details

Contact Number:

Contact Email:

Property

Property Address:

City :

State:

Zip :

Mailing Address (if different from property):

City :

State:

Zip :

Property Information:

Living at address for less than 3 years?:

Prior adress:

City :

State:

Zip :

New Purchase:

Closing date:

will you be moving into home within 30 days of closing?

Year built:

Square footage:

Construction Type:

Is this home a Condo?

does a condo association manage the home? :

Name of Association:

Has the home been updated?:

Plumbing:

Heating:

Electric:

Roof:

Number of Families:

Foundation Type:

Basement Type:

Intended Home Occupancy:

Is The Property Under Renovations?:

Will home be Occupied Within 30 Days:

Description Of Renovation:

Any pool, Trampoline, Business on premises? :

Comments :

Security Features:

Sprinkler System Full

Sprinkler Partial

Central Station Fire Alarm

Central Station Burglar Alarm

Local Fire Alarm

Local Burglar Alarm

Surveillance Video

Security Guard

Smoke detector

Appraisal Report or Current Policy:

Current Insurance:

Current Carrier Name:

Expiration Date:

Current Premium:

Losses:

Please provide details for the loss

Coverage:

Would you like to request specific Coverage:

Dwelling Amount:

Personal Property Amount:

Liability amount:

Deductible Amount:

Mortgage?:

Please provide Name/address and loan # of bank.

Homeowners

Applicant

Property

Property Information:

Coverage: