New Vision Insurance Agency, Inc. can provide you with great rates for homeowners insurance, including Florida homeowners insurance.  When you request a quote from us you are under no obligation to purchase a policy.  You may request a quote for home owners insurance by completing and submitting the following form.  If you prefer, you may call us, or stop by our office during business hours.  Your information will be used for the sole purpose of obtaining a quote, and will NEVER be sold or misused.  An agent may contact you using your preferred method if, for any reason, additional information is required to be able to provide you with a quote.

SECTION ONE: Your Personal Information

(If there is any information you are unsure of, please enter 'unsure' in your answer.  We can always help you find that information if necessary.)
E-MAIL ADDRESS: TELEPHONE:
YOUR FULL NAME: FAX:
OCCUPATION: DATE OF BIRTH:
S.S. # DEVELOP/CONDO NAME:
PROPERTY ADDRESS: CITY:
STATE: ZIP:

SECTION TWO: Property Information
YEAR BUILT: APPROX. VALUE:
SQUARE FEET: NUMBER OF FLOORS:
TYPE OF PROPERTY 
(Single Family/Condo etc)		 NUMBER OF UNITS:
ROOF TYPE: CONSTRUCTION TYPE:

PROPERTY ADDRESS (if different to Section One):
STREET ADDRESS

UNIT / APT #
CITY: STATE:
ZIP: COUNTY:
1: Do You Own Any Dogs?  NO  YES     If YES, What Breed?
2: Do You Own A Boat?  NO  YES     3: Does the property have a pool?   NO YES
4: Does the property have shutters?   NO  YES     5: Is the property used for business?   NO YES
6: Is the property used for rentals?   NO  YES    

7: Any smokers in the home? NO  YES

Alarm Central Station Reporting?   

  BURGLARY    FIRE

Did you have any Bankruptcies or Foreclosures during the past three years?

 NO  YES
Residence Use: PRIMARY  SEASONAL  SECOND
Occupancy: OWNER  TENANT  SECOND

    Please detail any claims during the last three years:

SECTION THREE: Coverage Amounts
BUILDING: ADDITIONAL BUILDINGS:
CONTENTS: LOSS OF USE:
LIABILITY: LOSS ASSESSMENT:

DEDUCTIBLES:  ALL PERILS:     HURRICANE:

Who insures your automobiles? 

Additional Amounts:
JEWELRY: GUNS: FUR: ART:
PREFERRED METHOD OF CONTACT - Please tell us how you would prefer to receive your quote:
(Enter your contact information in the preferred field)

E-MAIL:   TELEPHONE:   FAX:

IF YOU HAVE ANY ADDITIONAL QUESTIONS, COMMENTS OR INFORMATION - please enter it in the following field:

 

Agents are ready to assist in English or Creole - NOU PALE KREYOL

NEW VISION INSURANCE AGENCY, INC.

2900 14th Street N. Suite 58, Naples FL 34103

Phone: 239-261-5802  Fax: 239-261-5902

E-mail: info@newvisionins.com