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Marquis Brokerage
All Forms of Insurance

11 Broadway Suite #440
New York, NY 10004

Toll Free: (800) 711-4911
Local: (212) 825-0055
Fax Numbers: (212) 825-0955
(718) 980-5676
 
Co-op/Condo Insurance Application

Personal Information
Last Name

First Name

Name of insured (if different from above)

Social Security Number
 
-
   
-
  
Date of Birth
 
/
   
/
  
Home #
(
   
)
    
-
  
Work #
(
   
)
    
-
  
Fax #
(
   
)
    
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Email Address

Property Information
Address of Property(s) to be insured

Approximate value of dwelling

Umbrella policy desired?
Yes   No
Number of Floors in Building
Number of Apartments in Building
Including Off Premises Theft   Excluding Off Premises Theft
Any Claims?
Yes   No     Closing Date
Prior Insurance Carrier

Miles to the Fire Dept
Feet from a fire hydrant
Personal property
$25,000   $30,000   $40,000   $50,000   Other
Desired property deductible
$500   $1000   Other
Liability
$100,000   $300,000   $500,000   $1,000,000
Medical payments to others
$1000   $5000   Other

Scheduled Items
Items you wish to cover for the full amount of their value, which may be excluded or items not covered for their full value
(include dollar values for all scheduled items)
Jewelry $     Furs $     Silverware $
Fine arts $     Cameras $     Firearms $
Antiques $     Musical Instruments $
Fine China $     Crystal $     Bikes $
Copyright 2003 Marquis Brokerage | All Rights Reserved.
An ITS Production