Landlord Quote Last Name First Name M. I. Physical Address City State Zip County Mailing Address (if different) City State Zip County Email Home Phone Cell Phone Work Phone Building Construction Type   Please Select Frame Stucco Brick/Stone Shingle/Wood Siding Aluminum/Vinyl Siding Number of Units   Please Select One-Family Two-Family Three-Family Four-Family More Year Built   Date of last update to Plumbing   Date of last update to Heating   Date of last update to Roof   Date of last update to Wiring   Within 1,000 ft of Fire Hydrant   Please Select Yes No Distance to Fire Department in Miles   Amount of Insurance for Building   Amount of Insurance for Contents   Building Valuation   Please Select Replacement Cost Actual Cash Value Liability Amount   Please Select 100,000 300,000 500,000 1M Med Pay   Please Select 1,000 2,000 4,000 5,000 Deductible   Please Select 250 500 1,000 1,500 2,000 Smoke Detectors?   Please Select Yes No Carbon Monoxide Detectors?   Please Select Yes No Alarm?   Please Select Central Station Local Alarm Sewer and Drain Coverage?   Please Select Yes No Claims/losses in the last 5 years   Please Select None 1 2 3 4 More Please provide date, amount and brief description of each incident   Present Insurance Company   Renew Date   Are you being Cancelled?   Please Select Yes No Add Landlord Umbrella/Landlord Catastrophe Liability coverage?   Please Select 1M 2M 3M 4M 5M Not at the time Do you have any questions or additional information/comments?         Bradley Agency Disclaimer for On-Line Quote By choosing to use this web site (bradleyagency.com) to request an insurance quote, you agree to the following terms and conditions. The materials and information contained in this web site are provided “as is” and without warranty of any kind, either expressed or implied.  The Bradley Agency assumes no liability whatsoever for damages of any kind incurred as a result of your request for a quote or use of this website. Your request for an insurance quote will not bring into effect any insurance coverage.  Insurance coverage may only be effected when your application for insurance is accepted by the Bradley Agency and approved by the carrier as evidenced by the inception date as indicated on a policy. Your entire quote, including the estimated premium and the prospective terms of coverage are tentative and are subject to change without notice based on any and all underwriting criteria, rating dates, manuals, plans and classifications used by Bradley Agency. In the event that there is a difference in the information, rates, premiums or terms contained in a quote and any insurance policy issued to you by the Bradley Agency, the policy governs.

2022 Western Avenue • Albany NY 12203 • Office hours: Monday - Friday 9:00am - 5:00pm
Phone: 518.452.2736 • Fax: 518.452.2851 • Email: insurance@bradleyagency.com