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4898 State Route 52
P. O. Box 682
Jeffersonville, NY 12748

(845) 482-5510

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Mike Preis Insurance
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Home Replacement Cost Questionnaire

Your Contact Information

First Name:*

Last Name:*

Title:

Email Address:*

Phone Number:*

Policy Number:

How would you like us to follow up with you?

Email Phone

Home Information

Zip Code of Property:*

Year Built:

Square Footage:*

Type of Residence:*

Substructure:*

Exterior Walls:*

Number of Stories:*

Bathroom Grade:*

Number of Baths:*

Roof Design:*

Roofing Material:*

Wall Height:*

% of Home with Cathedral Ceiling:*

Garage:*

Open Porch Sq. Ft.

Closed Porch Sq. Ft.

Wood Deck Sq. Ft.

Irregular Corners:*

Yes No

Fireplace:*

Yes No

Central Heat/Air:*

Yes No

Jacuzzi:*

Yes No

Hot Tub:*

Yes No

If you have a pool, does it have a diving board or a slide?*

Yes No N/A

If you have a pool is it: screened in or is it fenced in with a fence that is higher than 4 ft?*

Yes No N/A

If you have a pool, is access to pool area controlled with a locking gate? *

Yes No N/A

Questions or Comments

Binding Agreement

(Required) I understand that any policy changes and quote requests are effective only when I have received a written confirmation.*

I agree

*Required fields:

This submission is a request. Insurance coverage changes and new coverages are not effective until we confirm that for you.

We will do our best to complete this request based on the information you provide. The more complete your information, the more accurate your quote will be.

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Address:

Mike Preis Insurance
4898 State Route 52
P. O. Box 682
Jeffersonville, New York 12723
Phone: (845) 482-5510
Fax: (845) 482-3459

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Home Replacement Cost Questionnaire

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