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Personal Information
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*First Name
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*Last Name
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Mailing Address
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City/St/Zip
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*Phone Number
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Alternate Number
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Birth Date
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*Email Address
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Property Information
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Property Street Address
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Dwelling Type
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Number of Bedrooms
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Number of Bathrooms
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Number of Fireplaces
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How many porches or decks are there?
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What year was it built?
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What date was the property purchased?
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What is the construction type?
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How many stories is it?
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If two stories, what is the ground floor square footage?
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Total square footage
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What is the property's topography?
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What foundation type?
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If structure is located in a flood zone, what is the distance to body of water?
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Garage Description
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What type of roof covering?
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Was the roof updated?
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YesNo
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If yes, what year?
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Does the building have a pool?
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YesNo
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If yes, is it fenced? YesNo
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If there is a pool, is there a diving board?
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YesNo
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If there is a pool, is there a slide? YesNo
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What is the distance to fire protection?
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Is the building in the brush?
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YesNo
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Is there a brush hazard within one mile of the building?
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YesNo
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If yes, has the brush been cleared by 250 feet from all sides of the building? YesNo
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Is there a smoke alarm installed?
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YesNo
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Is there a fire extinguisher?
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YesNo
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Are there deadbolts?
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YesNo
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Is the electrical updated?
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YesNo
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Are there circuit breakers?
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YesNo
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Does the electrical circuit box have copper wiring?
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YesNo
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How old is the heating/ air conditioning?
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Is the heating / air conditioning thermostatically controlled?
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YesNo
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What is the energy source?
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What is the heating system?
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What is the cooling system?
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Has the plumbing been updated?
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YesNo
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Is the plumbing copper?
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YesNo
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Does the building have interior automatic fire sprinklers?
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YesNo
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Is there a theft alarm?
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YesNo
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What is the earthquake zone?
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Has it been earthquake retroffited?
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What is the fire district?
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Are there dogs on the property?
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YesNo
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If yes, how many and what is the breed of each dog?
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Are there any other pets or animals on the property?
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YesNo
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If yes, how many and what is the description of each?
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Current Coverage Information
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Current Insurance Company
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Expiration Date
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Were there any losses or claims in the last 5 years?
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YesNo
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If yes, what is the date, amount paid and description of each loss or claim?
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Desired Coverage Information
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Dwelling Amount - Coverage A
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Other Structures - Coverage B
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Personal Property - Coverage C
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Loss of Use - Coverage D
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Premise Liability - Coverage E
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Policy Deductible
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If earthquake insurance is requested, select deductible percentage %
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Do you want building replacement cost coverage?
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YesNo
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Do you want contents replacement cost coverage?
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YesNo
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Questions or Comments
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Best Time To Contact You
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Please let us know the best time to call and discuss your quote
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MorningAfternoonEveningAnytime
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Or Specify Other:
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