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Building Information

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Type of Home *

Year Built *

Construction Type *

Foundation *

Roof Type *

Roof Age *

Square Footage *

Primary Heating *

Bedrooms *

Bathrooms *

Stories *

Garage Type *

Select any additional property features that apply. *

Is your home located in a flood plain? *

Security System *

Municipal Location *

Fire Alarm *

Do you have any of the following breeds of dogs: Chow, Doberman, German Shepherd, Pit Bull, Rottweiler, Wolf Hybrid, or a mix of these? *

Policy Information

Approximate Replacement Cost of Dwelling (not including land) *

Personal Liability Coverage Desired *

Desired Deductible *

When would you like this policy to start? *

Have you reported any claims or losses to your insurance company within the past 5 years? *

Will this insurance replace an existing policy? *

Credit Rating *

Contact Information

Name *

First

Last

Email *

Phone Number *

Address *

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Additional Comments? *

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Martin & Murray Wealth Solutions, LLC
60 E 42nd St.
New York, NY 10165
(877) 288-PLAN (7526)
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DISCLAIMER: Securities and investment advisory services offered solely through Ameritas Investment Corp. (AIC). Member www.FINRA.org / www.SIPC.org. AIC is not affiliated with Martin & Murray Wealth Solutions, LLC or other entities mentioned in this website. Additional products and services may be available through registered associates of Martin & Murray Wealth Solutions, LLC that are not offered through AIC. Securities products are limited to residents of CT, NY and NJ.

This is not an offer of securities in any jurisdiction/ nor is it specifically directed to a resident of any jurisdiction. As with any security, request a prospectus from your Registered Representative. Read it carefully before you invest or send money. A Representative from Martin & Murray Wealth Solutions, LLC will contact you to provide requested information.

Representatives of AIC do not provide tax or legal advice. Please consult your tax advisor or attorney regarding your situation.