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PROPERTY LOCATION
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Please fill in all fields for an accurate quote |
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NAME:
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PHONE NUMBER:
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ADDRESS:
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CITY/STATE/ZIP:
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E-MAIL:
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YEAR BUILT:
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(Please enter 4-digit year) |
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STRUCTURE TYPE:
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NUMBER OF STORIES:
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NUMBER OF BEDROOMS:
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NUMBER OF BATHROOMS:
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SQUARE FEET:
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ROOF COVERING:
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FOUNDATION TYPE:
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GARAGE TYPE:
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IF STRUCTURE IS LOCATED IN A FLOOD ZONE, SELECT DISTANCE TO BODY OF WATER:
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IS STRUCTURE LOCATED WITHIN A BRUSH HAZARD AREA?:
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DOES THE PROPERTY HAVE EARTHQUAKE DAMAGE?:
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| AMENITIES |
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HEATING SYSTEM:
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COOLING SYSTEM:
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FIRE PLACES:
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PORCHES/DECKS:
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DO YOU HAVE A SWIMMING POOL OR SPA?:
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SECURITY/SAFETY
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BURGLAR ALARM:
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FIRE ALARM SYSTEM:
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FIRE SPRINKLER SYSTEM:
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FIRE EXTINGUISHERS:
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SMOKE DETECTORS:
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DOES ANYONE IN YOUR HOUSEHOLD SMOKE?:
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DESIRED COVERAGE INFO
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POLICY DEDUCTIBLE:
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STRUCTURE VALUE (does not include land value):
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$ (Enter cost to rebuild main structures) |
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PERSONAL PROPERTY COVERAGE:
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$ (Enter cost to replace personal possessions) |
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EARTHQUAKE INSURANCE:
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FLOOD INSURANCE:
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CURRENT COVERAGE INFO
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HAVE YOU FILED ANY HOMEOWNER'S CLAIMS IN THE PAST THREE YEARS?:
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HAVE YOU EVER FILED FOR BANKRUPTCY?:
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DO YOU CURRENTLY HAVE INSURANCE ON THIS PROPERTY?:
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(if answered NO, do not fill out rest of form) |
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CURRENT CARRIER:
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EXPIRATION DATE:
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CURRENT DEDUCTIBLE:
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PERSONAL LIABILITY
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PERSONAL PROPERTY:
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MEDICAL PAYMENTS:
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EARTHQUAKE COVERAGE:
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$ |
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EARTHQUAKE DEDUCTIBLE:
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$ |
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PLEASE SEND ME MONEY SAVING OFFERS ON AUTO INSURANCE |
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AUTO POLICY EXPIRATION DATE (if box checked above):
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CURRENT AUTO INSURANCE CARRIER:
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