HOMEOWNERS INSURANCE QUOTE		We would like to provide you with a free, no-obligation homeowners insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only. This is not an application for insurance, and it does not obligate this agency to issue any policy of insurance. Despite the security measures taken, there are inherent risks of disclosing personal info on the website. If you are concerned, please feel free to call, fax, or mail at your convenience.

Personal Information
Name:
Address:
City:	State:   Zip:
Day Phone:	Night Phone:
Best Time To Call:	AM   PM
Email Address:
Occupation:	How Long At Current Job:

Current Homeowners Insurance Information
Company Name (not agency):
Policy Expiration Date:	Premium Amount: $
Amount Insured For:	$     Policy Type: Primary Secondary
Term:	6 Months   1 Year   Other:

Home Information
How Long At Present Address:	Year Home Was Built:
Sq. Footage (excluding garage and basement):	sq. ft.         # of Claims In Last 3 Years:

Structure Information
Type	Construction	Roof	Foundation	Garage
1 Story 1 1/2 Story 2 Story Split Level Bi-Level Other	Frame Stucco Veneer Masonry Other	Asphalt Shingle Wood Shingle Tile or Slate Other	Basement Crawl Space Slab Other	1 Car 2 Car 3 Car 4 Car None
		Age of roof: yrs.		Attached Detached Basement Built-in Car Port None

Features
Bathrooms	Basement	Deck/Porch/Patio	Fireplaces
# of Full: # of Half:	None Finished Unfinished Sq. Ft.:	Deck Sq. Ft.:     Porch Sq. Ft.:     Screened Patio Sq. Ft.:	# of Chimneys:     # of Hearths:

Additional Features
Heating System	Central Air	Central Vac	Security Alarm	Fire Alarm	Smoke Detector
None Electric Gas Oil Propane Solar Other	Yes	Yes	None Monitored Not Monitored	None Monitored Not Monitored	Yes
Trampoline	Swimming Pool		Do You Own a Dog?
			Yes/No	Breed	Biting History
Yes	Above Ground	Below Ground	Yes

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

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HEDLEY BROOK AGENCY, INC.
818 W. State Street, P.O.B. 585, Olean, New York 14760-0585 USA
Tel: 716-372-1122 · Fax: 716-372-1143
TOLL FREE (NY-PA-FL) 1-877-414-1122
info@hedleybrook.com

This is not an offer to sell insurance in any place except the state of NY, USA

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