new york homeowners insurance from ProActive Brokerage of Babylon, NY

 


On-Line Vacant Land
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!


Your Personal Data:
 
Your Name:
Property Address:
City:
State (Must be New York):
Zip/Postal:
E-Mail (REQUIRED):
E-Mail (again for accuracy):
Phone:
Fax (optional):
 
Dwelling Information
 
Full Address of Vacant Land:
Total Acreage:
 
Are You Near Brush Area? Yes No
 
# of feet to nearest
fire hydrant:
# of miles to nearest
fire station:
 
Currently Insured? Yes No
Name of Carrier & how long insured?
 
Prior Claims? Yes No
Describe claims in detail:

Describe Any Structures on Land:
 
Coverages:
 
Liability Limit Requested $
 
Comments/Remarks
(describe any other special coverages needed here):
 
Send my quotation via: E-Mail Fax
Regular Mail
Call me by Phone

Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me a Quote NOW!


Enter code at right, here:
Web Form Protection Code

Click Button Below When Done

Please Click Only Once . . . May take up to 30 seconds!




ProActive Brokerage  |  Terms of Use/Privacy Notice/Copyright Info.  | Map/Driving Directions  | About Us  | Service
Please report site-related technical problems to: info@proactivebro.com | Visit the ProActiveBro.com Main Website
Our Office Address: 926 Sunrise Hwy | West Babylon, NY 11704

Web Site Design © 2018 Insurance-Web-Sales