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Agent!

 
E-mail Questions to:
sales@norton
andsiegel.com

 

Toll-Free: 1-800-669-0040
Phone: 1-631-669-0365
Fax: 1-631-669-0158

Contact Address:
Norton & Siegel, Inc.
PO Box 220
Babylon, NY 11702

"Remember, All Our Policies Come With an Agent!"
On-Line Renters
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!


Your Personal Data:
 
Your Name:
Property Address:
City:
State: (Must be New York)
Zip/Postal:
E-Mail (REQUIRED):
E-Mail (again for accuracy):
Phone:
Fax (optional):
 
Dwelling Information
 
Year Dwelling Built:
Home Square footage:
 
# Units in common bldg.:
 
Type Roof: Shingle Wood Shake
Tar/Gravel Spanish Tile
 
Number of stories: One Two
Three 4+
 
Do you own animals or pets? Yes No
If yes, list type/for dogs, list breed:
 
Are You Near Brush Area? Yes No
 
# of feet to nearest
fire hydrant:
# of miles to nearest
fire station:
 
Currently Insured? Yes No
Name of Carrier & how long insured?
 
Prior Claims? Yes No
Describe claims in detail:
 
Plumbing type: Copper Galvanized
Mixed (Copper/Galvanized)
 
Circuit Breakers or fuses? Breakers Fuses


# Fireplaces: # Chimneys:
 
Special features
(i.e., deck, air conditioning, alarm systems, pool, etc.)
 
Coverages:
 
Contents $ Loss of Use $
Liability Cov. $ Deductible $
($250, $500, $1,000, etc.)
 
Comments/Remarks
(describe any scheduled jewelry, in-home business, or other special coverages needed here):
 
Send my quotation via: E-Mail Fax
Regular Mail
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Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

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Norton & Siegel, Inc. | PO Box 220 | Babylon, NY 11702 | Phone: 1-631-669-0365 | Fax: 1-631-669-0158
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