Let’s start with your name, email & phone

Tell us about the primary insured and how to reach them.

First Name*

Last Name*

Enter your email*

Cell Phone Number*

Home Phone Number

Work Phone Number

Date of Birth

Marital Status*

Second insured (optional)

Second Insured Name

Date of Birth

Referred by

Step 1/4

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Property information

Where is the property located and what's its occupancy status?

Property Address*

City*

State*

ZIP Code*

Occupancy*

Weeks Rented/Occupied

Claims in past 5 years? (check if yes)Yes, I have had one or more claims

Trust / Corp / LLC / Mortgagee (if applicable)

Entity name

Entity address

Trustees

Step 2/4

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Home Characteristics

Basic structure and construction details about the property.

Year Built*

Square Footage*

Style

Construction Type*

Exterior Finish*

Heat Source*

Oil Tank*

Age of Tank (years)

Fireplace*

Garage

# of Garage Cars

Kitchen*

Bath*

Number of Full Bathrooms*

Number Half Bathrooms

# of Sliding Doors

# of Skylights

# of Picture/Bay Windows

Pool*

Diving Board?*

Slide?*

Renovations

Roof last replaced

Plumbing last updated

Electrical last updated

Step 3/5

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Additional Rebuild Information

Flooring

Roof Material

Foundation*

Basement % finished

Alarm Type

Number of families*

Electrical

Dogs on property*

Dog Breed (if applicable)

Porch (sq ft)

Deck (sq ft)

Patio (sq ft)

Sunroom (sq ft)

Include Jewelry Coverage?*

Jewelry Description (if applicable)

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Finally, Prior insurance coverage

Details about your current or most recent homeowners policy.

Prior Carrier,Limits, Address

Prior Carrier

Date of Renewal or Cancellation

Notes on Prior Claims & Occupation

Step 5/5

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Thank you! Your submission has been received!
A member of the JSM Brokerage team will be in touch shortly.
Questions? Call (631) 765-2777

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