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Avolese Insurance Agency LLC
150 Broadhollow Road - PH6
Melville, N.Y. 11747

Tel  631-673-9171
Fax 631-673-0364


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Dec 1, 2017
Avolese Insurance Agency proudly announces our redesigned website. We've added a great deal of helpful information to make navigating the world of insurance products a bit easier. Check back often as we continue to add more beneficial features.


Homeowners Insurance Application

Contact Information
First Name * Phone Number (evening)
Middle Initial Phone number (daytime) *
Last Name * Email Address of person requesting quote *
Address * Name of your Realtor, if any
City *    
State *    
Zip *    
Property Information
Property Street * Zip *
City * County
State * Township, Borough or Municipality
    Insured's previous address
Applicants
Name Birthdate (month/day/year) SSN Occupation
1  *
2 
3 
4 
Questions
What is the effective date? Do you have a swimming pool at this home? * Yes     
No
If you have a pool, is there a fence around it? Yes     
No
Is this home within 1000 feet of a fire hydrant? Yes     
No		 Do you have a wood, kerosene or oil stove in this home? Yes     
No
How far to the nearest Fire Department Is there a trampoline at your home? Yes     
No
Is this home your main residence or a second home? Primary     
Secondary		 Do you operate a business from within your home? Yes     
No
Describe the construction of your exterior walls * Electric Service: 100 Amps or more? Yes     
No
Number of Stories 1    2    3    Protection Type Breakers     
Fuses
What year was your home built? * Is there a finished basement? Yes     
No
If older than 20 years, when were the following updated:
Plumbing:
Heating:
Electrical:
Roof:
Is there a deck? Yes     
No
What is the approximate lot size? If there is a deck, how many square feet is it?
How many square feet is this house? * How many fireplaces? 0  1  2 
3  4 
Number of units in the home? How many bathrooms? 1    1.5 2   
2.5 3    4
Describe the style of your home? Style of garage?
Type of heat? Oil     
Electric
Gas		 Garage holds how many cars? 0  1  2 
3  4 
If Oil, location of tank Is the home air conditioned? Yes     
No
On your existing home, how many claims have you reported in the last five years? 0  1  2 
3  4 		 If air conditioned, type of system?
Do pets or exotic animals live in this home with you? Yes     
No		 Does the home have an alarm system? Yes     
No
Name of Mortgage Company Address of Mortgage Company
Current Coverage
Policy Expiration Date Current Carrier
Current Premium Amount of coverage?
Amount of personal liability coverage? Medical coverage (Good Samaritan) ?
Property deductible?    

* Required Field

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