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We offer special coverage for your home and additional discounts on new homes and policy discounts for home and auto.

Fill out our secure quote request form below and a Park Insurance Associates agent will
contact you soon. Please fill all applicable fields. Please read our privacy statement before

City, State, Zip
Type of Heating oil gas other
If oil heat, where is the oil tank located
If home has an oil tank, is it located above or below the ground? above below
Are you located within 500 ft. of any bodies of water? yes no
Purchase price of home
Balance on Mortgage
Home phone number
Work phone number
Age of home (years)
Is your home brick or frame? brick frame
Any claims in the past 3 years?
If yes, explain in full
yes no
What is the distance between your home and the next structure to your left, right , and behind you.
to the left
to the right
behind you
Any dogs? If Yes, explain number
breed(s), and age(s)
yes no
If any dogs, please list predominant breed and age
Any swimming pools? If yes,
how is it protected
yes no
Any trampolines on the premises yes no
Does anyone conduct a business from the insured premises? If yes, please explain yes no
Does the dwelling have a flat or pitched roof? pitched flat not sure
Did you have any lapse in coverage?
If yes, how long?
yes no
Has any company cancelled you in the past 3 years? If yes, explain. yes no
Date Insurance is needed?


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