Viale Insurance Agency

Required fields are denoted by *

Yes, I would like a quote for the following type of insurance

Homeowners Insurance Renters Insurance

*First Name
*Last Name
*E-mail
*Phone #
Property Address
Mailing Address

Year Built

Construction:

Usage:

Structure Type:

Occupied By:

Primary Heat Type:

Seconday Heat:

# of Families:

Dwelling Coverage Amount

Deductible Amount:

Distance to a fire hydrant

Distance to fire department:

Protection Device Type

Burgalar Alarm      Central     Local

Fire Alarm            Central     Local

Smoke Detectors       Yes     No

Swimming Pool

Yes No

Renovation Types

Wiring Year

Plumbing Year

Heating Year

Roof Year

Pets owned:

Dogs Yes No

Horses Yes No

Any coverage declined, canceled or non-renewed in the last 3 years:

Yes No

Any losses/claims in the last 3 years.

Yes No
If yes, please provide us with the approximate date, type of claim (e.g. windstorm, water damage, fire loss), and the amount of loss (add this info in comment box)

Do you operate a business out of your home?

Yes No

If yes, type of business:

Additional Comments

Make sure you're properly protected. Call us for a
free review and evaluation of your present coverage.

Protect the things that mean the most to you.

E-mail or call Paul Viale today at (413) 243-0347
Our office fax# is 413-243-2536
Monday - Friday from 9am - 4:30 p.m.

Site design & development by Business Marketplace