Homeowners/Rental Property Insurance Quote Request Form

To request a quote, please take a moment to fill out our quick Homeowners/Rental Property Insurance Quote request form.
One of our agents will get back to you promptly. Thank you for choosing Northeastern Group!

Personal Information
First Name: Last Name:
Address 1:
Address 2:
City: State: Zip:
Home Telephone:
Email Address:

Subject Property Address

Mortgage Information
Mortgage Company Name:
Mortgage Company Address:
Loan Number:
Do you currently have
homeowners insurance?
What is the expiration date of
your current Homeowners
Insurance Policy?
Do you own or rent?
How were you referred? Yellow Book Verizon Yellow Pages Radio Television
Internet Word of Mouth Other

Coverage amount or limit of liability requested
HomeOther structures (detached
garages for example)
Personal property or
Loss of use
Personal Liability
Medical Payments
Deductible for property
Number of Units?
Construction Type:Year Built?
Market ValueDistance to nearest fire
hydrant in feet
Distance to nearest
fire hall in miles
Do you have smoke
Do you have burglar

Is any business conducted within this home?
Has any coverage been declined, cancelled or not-renewed during the last 3 years?
If you rent, answer the following questions:
What is the replacement cost
value of your personal items?
What deductible would you
prefer for your rental policy?

What are your Personal Liability
limits for your rental policy?

Can't read the image? click here to refresh

About Us | Privacy Policy | FAQ's | Contact Us

© 2011-2012 Northeastern Group, LTD. All Rights Reserved. Main Office: 695 Hempstead Turnpike, Franklin Square, NY 11010