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Joshua J. Stephen Associates Insurance Agency
516-481-5010- NY
516-203-7168- NY Fax
954-323-4136- FL
954-323-4052- FL Fax
Please tell us a little about yourself
Name
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First
Last
Co-Applicant Name
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First
Last
Email
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Co-Applicant Email
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Phone Number
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Co-Applicant Phone Number
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Date of Birth
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Co-Applicant Date of Birth
*
Occupation
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Co-Applicant Occupation
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Mailing Address
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Line 1
Line 2
City
State
Zip Code
Country
Now please tell us a little about your property
Type of Residence:
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Primary
Seasonal
Investment / Rental
Address (If different than above)
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Line 1
Line 2
City
State
Zip Code
Country
Currently Occupied?
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Yes
No
Please describe any claims activity associated with this property
*
Help us help you. Please upload the following documents if available:
Previous Policy Declarations Page
*
Max file size: 20MB
Wind Mitigation Report
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Max file size: 20MB
Four Point Inspection
*
Max file size: 20MB
Alarm Certificate
*
Max file size: 20MB
Sprinkler Certificate
*
Max file size: 20MB
Would you like a Flood Quote as well?
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Yes
No
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