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HOMEOWNERS INSURANCE QUOTE REQUEST
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Complete the following
information if you would like to obtain a quote on Homeowners Insurance.
Please understand this is not an application for insurance. An application
will be sent to you if coverage is desired.
All information provided on this information
sheet is confidential and will be used solely for the purpose of
developing a quote for you. |
The home may be a single family owner occupied dwelling (home),
condo or townhome. This program may provide dwelling fire
coverage, contents - personal property, loss of use, separate
structures such as a detached garage or shed, premise medical
and premise liability insurance.
Complete this form to get a quote on a single family owner
occupied home, condo or townhouse.
You can also get a quote on:
Rental Property (1-4 units)
Mobilehome
Apartment Building
(5+units)
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| Personal Information |
| What is your name? |
Last
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First
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Middle
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| What is your mailing
address? |
Street
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City
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State
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Zip
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| What is your telephone
number? |
Home
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Work
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| What is your fax number? |
Fax
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| What is your email address? |
Email
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| Property Information |
| What is
the property address? |
Street
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City
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State
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Zip
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| What is the dwelling type? |
Dwelling Type
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| How many bedrooms are there? |
Number of Bedrooms
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| How many bathrooms are there? |
Number of Bathrooms
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| How many fireplaces are there? |
Number of Fireplaces
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| How many porches or decks are there? |
Porches or Decks
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| What year was it built? |
Year Built
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| What date was the property purchased? |
Purchase Date
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| What is the construction type? |
Construction Type
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| How many stories? |
Stories
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| If two stories, what is the ground
floor square footage? |
Ground Floor Square Footage
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| What is the total square footage
of the building? |
Total Square Footage
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| What is the property's
topography? |
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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| What type of garage? |
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| What type roof covering? |
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| Was the roof updated? |
Updated Roof
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Yes
No |
| If yes, what year? |
Year Roof Updated
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| Does the building have a pool? |
Pool
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Yes
No |
| If there is a pool, is it fenced? |
Pool Fence
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Yes
No |
| If there is a pool, is there a
diving board? |
Pool Diving Board
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Yes
No |
| If there is a pool, is there a
slide? |
Pool Slide
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Yes
No |
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What is the distance of fire protection?
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| Is the building in the brush? |
Brush
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Yes
No |
| Is there a brush hazard within
one mile of the building? |
Brush Within 1 Mile
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Yes
No |
| If yes, has the brush been cleared
by 250 feet from all sides of the building? |
Brush Cleared by 250 Feet
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Yes
No |
| Is there a smoke alarm? |
Smoke Alarm
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Yes
No |
| Is there a fire extinguisher? |
Fire Extinguisher
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Yes
No |
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Deadbolts
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Yes
No |
| Is the electrical updated? |
Electrical Update
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| Are there circuit breakers? |
Circuit Breakers
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Yes
No |
| Does the electrical circuit box
have copper wiring? |
Copper Wiring
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Yes
No |
| How old is the heating/ air conditioning? |
Age Heating/ Air Conditioning
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| Is the heating/ air conditioning
thermostatically controlled? |
Thermostatically Controlled
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Yes
No |
| What is the energy source? |
Energy Source
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| What is the heating system? |
Heating System
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| What is the cooling system? |
Cooling System
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| Has the plumbing been updated? |
Plumbing Updated
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Yes
No |
| Is the plumbing copper? |
Copper
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Yes
No |
| Does the building have interior
automatic fire sprinklers? |
Automatic Fire Sprinklers
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Yes
No |
| Is there a theft alarm? |
Theft Alarm
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Yes
No |
| Is there a fire alarm? |
Fire Alarm
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Yes
No |
| What is the earthquake zone? |
Earthquake Zone
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| Has it been earthquake retrofitted? |
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| What is the fire district? |
Fire District
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| Are there dogs on the property? |
Dogs on Property
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Yes
No |
| 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? |
Pets or Animals
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Yes
No |
| If yes, how many and
what is the description of each? |
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| Current Coverage Information |
| What is the current insurance company? |
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| What is the expiration date of
current policy? |
Expiration Date
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| Were there any losses or claims
in the last 5 years? |
Losses - Claims
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Yes
No |
| If yes, what is the date, amount
paid and description of each loss or claim? |
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| Desired Coverage Information |
| Dwelling Amount |
Coverage A
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| Other Structures |
Coverage B
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| Business 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 |
Amount
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| If earthquake insurance is requested,
select deductible percentage % |
Earthquake Deductible
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| Do you want building replacement
cost coverage? |
Building Replacement Cost Coverage
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Yes
No |
| Do you want contents replacement
cost coverage? |
Contents Replacement Cost Coverage
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Yes
No |
| 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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Morning
Afternoon
Evening
Anytime
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Or specify other:
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