York-Jersey Underwriters, Inc.

To receive an accurate quote, all information should be included.
Please supply an e-mail, fax, mailing address or call
(800) 392-6958.

Name:
Address:
City, State, Zip:
Telephone:
E-mail:
Requested Effective Date:

Quote for Homeowners, Flood or Condominium.

Property Location (Address):	Nearest Cross Street:
Year Built:	Number of units in your section:
Brick Frame	Community #: (if known)
Dwelling Coverage Limits: $	or Unit Owners Building Limit: $
Contents Coverage Limit: $
Primary Heat Source:	If oil, is tank in ground: Yes No
Square footage of living space: (if known)	How many floors?
Is there a basement: Yes No	Is building elevated? Yes No
Built on Pilings? Yes No
Schedule of Personal Property:
Jewelry Limit: $ Fur Limit: $ Fine Art: $

Quote for Boat.

Year	Manufacturer
Length	Model
Number of Engines	Horsepower
Type of Fuel
Navigating Area:	Laid Up: From To
Inboard	Outboard
I/O	Top Speed
Purchase Price $	Insured Value $
Liability Limit $
Years of Boating Experience	Years as Boat Owner
Boating Education

York-Jersey Underwriters ~ P.O. Box 810 ~ Red Bank, NJ 07701
Conveniently located one mile east of the Garden State Parkway at exit 109
In eastern Monmouth County N.J.
(732) 842-2012 ~ (800) 392-6958 ~ fax: (732) 530-7080
E-mail: sales@york-jersey.com

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