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Home Owners’ Insurance Questionnaire

HOME OWNERS’ INSURANCE
QUESTIONNAIRE

NAME:

ADDRESS:

PRIOR ADDRESS (WITHIN PAST 5 YEARS):

OCCUPATION:

DATE OF BIRTH:

DATE OF BIRTH:

SOCIAL SECURITY #

SSN#:

LICENSE #:

LICENSE #:

CURRENT INSURANCE COMPANY:

CURRENT HOUSE LIMIT:

HAS ANY COVERAGE BEEN CANCELLED IN THE PAST 3 YEARS? IF SO WHY?

ANY SMOKERS IN HOUSEHOLD (Y/N)?

YEAR BUILT:

CONSTRUCTION (Frame/Masonry):

CUSTOM BUILT? (Y/N)

# STORIES (cape cod / ranch / split level / raised Ranch/colonial)

ROOF SHAPE:

TYPE OF SHINGLES: (Slate/Asphalt)

TOTAL LIVING FLOOR AREA:

BASEMENT: Square Feet: Finished/Unfinished

# FULL BATHS:

# 1/2 BATHS:

# KITCHENS:

# CAR GARAGE:

Attached / Detached / In Basement / Built In / Carport

FIREPLACE/WOODSTOVE:

PROFESSIONALLY INSTALLED? (Y/N)

PORCH: Square Feet:

Open/Closed:

DECK: Square Feet:

CENTRAL AIR: Separate Ducts/Same as Heating Ducts:

# SMOKE ALARMS:

DEAD BOLTS ON DOORS:

FIRE EXTINGUISHERS:

ALARM: BURGLAR / FIRE

CENTRAL STATION:

SWIMMING POOL: Inground/Above-ground

FENCED IN?

DIVING BOARD? SLIDE?:

BREED OF DOGS:

ANY OTHER ANIMALS?

IS THERE A DAY CARE CENTER ON PREMISES?

IS THE DWELLING FOR SALE?

HEATING: (Oil/Gas):

WHERE IS OIL TANK:

AGE OF TANK:

TRAMPOLINE: (Y/N):

YEAR OF UPDATE:

ROOF:

ELECTRIC:

PLUMBING:

HEATING:

PURCHASE PRICE:

MORTGAGE AMOUNT:

EXTERIOR WALLS: (BRICK, VINYL, SHAKES, ALUMINUM, ETC.)

INTERIOR WALLS: Plaster %

Sheetrock %

INTERIOR WALL COVERING: Paint %

Wallpaper %

Paneling %

FLOORS: Hardwood %

Carpet over Hardwood %

WALL TO WALL CARPET %

TILE: %

LINOLEUM: %

CEILING FANS:

BAY OR BOW WINDOWS:

PATIO DOORS:

SLIDING GLASS DOORS:

ATRIUM:

ANY : HOT TUBS, JACUZZI, CENTRAL VAC, WALK IN CLOSETS, SKYLIGHTS:

DOES BANK PAY THE PREMIUM?


Do you have insurance now?

Please attach a copy of your current policy for comparison

Fax/mail/email form to:

Graf Agency Inc.

1573 NY Avenue

Huntington Sta., NY 11746

Phone 631 423 2233

Fax 631 423 2619

Email marygraf@grafinsurance.com

  • Mary Graf has provided our small business with the knowledge, tools, and expertise to make informed decisions regarding our insurance investments. She is a warm and professional person who is highly motivated to do the absolute best for her clients and community.

    Brian Botticelli , Botticelli Prints Inc. Huntington, NY
  • Mary has been our insurance broker for many years. Her extensive knowledge of the companies and product offerings is critical to securing the best coverage for us. Her ability to ask the right questions, delve into the most relevant information and discern our requirements has forged a strong working relationship. Personally delightful and professionally efficient, Mary and her agency staff always provide top-shelf service!

    Fritzi Gros-Daillon , Anson Environmental Corp. Transitions USA Inc.
  • When I think of insurance, I think “Graf Agency.” I first joined our family business in 1984 and when I was introduced to Ken Graf, I soon realized why our family did business with his family.

    Over the years, Mary Graf has continued the family tradition of unmatched service, responsiveness and attention to detail. I know I can always depend on Mary to possess the knowledge, do the research and advise me on the best products for our business and my personal needs.

    The peace of mind that this provides is priceless.

    Joseph Fusaro , Green Energy Solutions AMJ Building Corp. Huntington, NY
  • As a Business Management Consultant with high-end clients who demand excellence, I only work with Mary from the Graf Agency for all my insurance needs.

    Mary’s response time, care and attention to my requests are always impeccable. Not only does she know her industry very well and provide the best packages, but she also takes the time to research the most cost-effective ways to make sure I am always offering my clients the very best!

    Evan Antonini, EHM Group, LLC Bookkeeping & Controllership Services New York, NY

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