Type of Quotation Requested

Homeowners Condo Renters

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Name
Address
City
State	Select California
Zip Code
Phone
Fax
E-Mail

Occupation
Self-Employed	Select No Yes

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Location of Property (if different than address shown above)

Address
City
State	Select California
Zip Code

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Underwriting Information

Approximate Size of Residence	(sq ft)
Approximate Year Residence was Built

If Built Prior to 1950, Date of Updates (if any)

Electrical
Heating
Plumbing
Roof

Construction	Select Frame Masonry Masonry Veneer Aluminum Siding Plastic Siding
Design	Select Dwelling Townhouse Condo Rowhouse Co-op Apartment
Garage	Select None Attached Unattached
Garage Capacity	Select One Car Two Car Three Car Four Car Four+ Car
Roof	Select California Shake Composition Rock Shake Tile Other
Usage	Select Primary Home Secondary Home Seasonal Home
Occupied by	Select Owner Tenant Vacant
Distance to Nearest Fire Station	(miles)
Distance to Nearest Fire Hydrant	(feet)
Do you own a pet	Select No Yes

If you own a pet(s), please describe (i.e. type of animal(s) and breed(s))

 

Check the Items Below that are Part of the Residence

Smoke Detectors
Dead Bolts
Swimming Pool
Fire Extinguisher
Patio/Deck
Central Alarm System
Do you own scheduled property (art, jewelry, etc.)	Select No Yes
Do you own other property	Select None Rental Property Secondary Home Other

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Loss History

Any Losses or Claims in the Last 3 Years?

Select No Yes

If yes, please provide details of each loss or claim in the last 3 years include date of the event(s), a description of the loss(es) and claim(s) and the amount (in dollars) of the loss(es) and claim(s)

 

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Homeowners Insurance Coverage/Deductible Information

Dwelling Coverage Limit
Deductible	Select 250 500 1,000

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Condo Insurance Coverage/Deductible Information

Personal Property Coverage Limit
Deductible	Select 250 500 1,000

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Renters Insurance Coverage/Deductible Information

Personal Property Coverage Limit
Deductible	Select 250 500 1,000

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Current Coverage Information

Are You Currently Insured	Select Yes No
Name of Your Insurance Company
Renewal Date of your Current Policy

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May We Also Provide You with a Quotation for

	Earthquake		Mobile Home		Fire
	Rental Properties		Umbrella		Flood