Personal Information
*First Name
*Last Name
Mailing Address
City/St/Zip
Phone Number
Alternate Number
Birth Date
*Email Address
Property Information
Property Street Address
How many units are in the building?
How many units in the building are vacant?
What year was it built?
What date was the property purchased?
What is the construction type?
Select Brick Stone Frame Masonry Superior Log Cabin Frame-Stucco Masonry Veneer
How many stories is it?
If two stories, what is the ground floor square footage?
What is the total square footage of the building?
What foundation type?
-Select- Crawl Space Piers-Pilings-Stilts Slab on Grade Unfinished Basement Walkout Basement Wood Foundation Basement
If structure is located in a flood zone, what is the distance to body of water?
-Select- Do not live in flood zone Less than 100 ft 100-500 ft 500-1000 ft More than 1000 ft
Garage Description
-Select- No Carport-Garage Car Carport Attached Car Carport Detached Garage Attached Garage Detached Tuck Under Parking Above Ground Parking Below Ground Parking Parking Lot Street Parking
What type of roof covering?
Was the roof updated?
Yes No
If yes, what year?
Does the building have a pool?
Yes No
If yes, is it fenced? Yes No
If there is a pool, is there a diving board?
Yes No
If there is a pool, is there a slide?
Yes No
What is the distance to fire protection?
-Select- 1000 ft or less to hydrant and 5 mi or less to fire station Over 1000 ft to hydrant and 5 MI or less to fire station Over 5 and up to 10 MI to fire station Over 10 MI to fire station
Is the building in the brush?
Yes No
Is there a brush hazard within one mile of the building?
Yes No
If yes, has the brush been cleared by 250 feet from all sides of the building?
Yes No
Is there a smoke alarm installed?
Yes No
Is there a fire extinguisher?
Yes No
Are there deadbolts?
Yes No
Is the electrical updated?
Yes No
Are there circuit breakers?
Yes No
Does the electrical circuit box have copper wiring?
Yes No
How old is the heating/ air conditioning?
Is the heating / air conditioning thermostatically controlled?
Yes No
What is the energy source?
-Select- Gas Electrical
What is the heating system?
-Select- None Heat Pump Electric Gas Oil
What is the cooling system?
-Select- None Central Air Evaporative Cooler
Has the plumbing been updated?
Yes No
Is the plumbing copper?
Yes No
Does the building have interior automatic fire sprinklers?
Yes No
Is there a theft alarm?
Yes No
What is the earthquake zone?
Has it been earthquake retroffited?
-Select- Not required - home built after 1975 Yes recently been bolted - retrofitted for EQ No
Tenant occupied?
Yes No
Are there dogs on the property?
Yes No
If yes, how many and what is the breed of each dog?
Are there any other pets or animals on the property?
Yes No
If yes, how many and what is the description of each?
Current Coverage Information
Current Insurance Company
Expiration Date
Were there any losses or claims in the last 5 years?
Yes No
If yes, what is the date, amount paid and description of each loss or claim?
Desired Coverage Information
Dwelling Amount - Coverage A
Other Structures - Coverage B
Personal Property - Coverage C
Loss of Use - Coverage D
Premise Liability - Coverage E
-Select- 100,000 300,000 500,000
Policy Deductible
-Select- 100 250 500 750 1000 2500 5000
If earthquake insurance is requested, select deductible percentage %
-Select- None 10 15 20 25 30
Do you want building replacement cost coverage?
Yes No
Do you want contents replacement cost coverage?
Yes No
Questions or Comments
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