Cafarelli Insurance Agency Ltd

Tel: 631.543.6363 Fax:631.543.4891
1030 Jericho Tpke. Smithtown, NY 11787

Cafarelli Realty

FORMS

Homeowner's Insurance

Professional Liability

Financial Services

Home Owner Application Form

Name(s)

Address

Date(s) of Birth Please enter the homeowner(s) date(s) of birth

SS Number(s) Please the homeowner(s) SS number(s)

Phone Number(s) Please enter phone number(s)

Prior Insurance Company Please enter the name of your prior insurance company

New Purchase Please indicate if this is a new purchase

Year Built Please enter the year the house was built in

Type of Home Please describe the type of home

Square Footage Please indicate the number of square feet

Number of Stories Please indicate the number of stories

Cost

Type of Heating System Please indicate the type of heating system

If Oil, indicate Tank Location If oil, please indicate tank location

Roof Material Please indicate the roof material

Foundation

% of Basemant Please indicate the % of basemant

% of Slab

% of Crawl Space Please indicate the % of crawl space

% of Basemant Finished Please indicate the % of basemant finished

Number of Bathrooms

Full

Half

Walls

Exterior Wall - What Kind and % Please indicate the kind and porcentage of exterior wall

Floor Covering - Kind and % Please indicate the kind and percentage of floor covering

Wall Covering - Kind and % Please indicate the kind and percentage of wall covering

Garage

Attached

Detached

Built In

Carport

Fireplace

Gas

Direct

Heating / Cooling Please indicate type of heating and cooling

Years of Updates

Roof

Plumbing

Wiring

Heat

Porche / Deck Square Footage Please indicate square footage for porche and deck

Pool

Diving Board Please indicate the presence of a diving board

Slide

Trampolin

Pets

What Kind and How Many Please indicate the kind of pet that you have and how many

Bite History (if any) Please describe the bite history (if any)

Electrical Panel

Circuit Breakers Please indicate the presence of circuit breakers

Fuses

AMPS

Alarm

Central Station Please indicate the presence of a central station

Burglar

Fire

Occupations Please describe the occupations of the people living in the house

Mortgagee

Escrow Billed Please indicate if the escrow was billed

Current Coverages

Coverage

Liability

Medical Payments Please describe your current medical payments

Deductible Please indicate your current deductible

Please enter your name:

Please enter your email address:

Serving the following towns of the Northshore and Southshore of Long Island:

Nassau County -Baldwin, Garden City, Levittown, Valley Stream, Manhasset, New Hyde Park, Port Washington, Cold Spring Harbor, Glen Cove, Great Neck, Lloyd Harbor, Muttontown, Hicksville, Oyster Bay, Old Brookville, Roslyn, Massapequa, Wantagh, Bethpage, Seaford, Syosset, Woodbury and the surrounding areas.

Suffolk County - Babylon, Lindenhurst, Bayshore, Bohemia, Hauppauge, Melville, Shirley, Mastic, West Islip, East Islip, Oakdale, Sayville, Bayport, Huntington, Northport, Stonybrook, Kings Point, Smithtown, Saint James, Port Jefferson, Setauket, Mount Sinai, Miller Place, Center Moriches, Selden, Holbrook, Ronkonkoma, Medford and the surrounding areas.

Also serving the Five Boroughs and Tri State Area.

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