Home Insurance Quote

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Name:                      
Sex:                       Male Female 

Marital Status:             SingleMarried

Property Address:          
                           

City:                        State: CA
County:                    
Zip Code: (Required!)      (California Only) 

Phone #:                   
Email:                      

Mailing Address if Different: 
                              

City:                         State: 
Zip Code:                     

Age of Owner:  Birth Date:  Social Security #: 

Occupation: 

Current Insurance Company and Policy #:  

Current Renewal Date:  Current Annual Premium:   

Reason for Shopping:  

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Property Information:

Type of Home: Tract Home Custom Home Townhouse/Condo Renters Insurance Rental Property (Landlord) DuplexTriplexFourplex Course of Construction  

Property Occupancy: Owner Occupied Tenant Occupied Renter Secondary

Construction: Wood Frame w/Stucco Wood Frame w/Wood Siding Brick Steel/Aluminum Frame  

Exterior Wall Type & Percentage:             (ie.stucco, wood siding/50% stucco & 50% wood siding) 

# of Stories: 1 1.5 2 2.5 3 4+ Townhouse/Condo Apartment Tri-Level  

# of Square Footage:  

Year Built:  

Please list any Renovations and year of completion.                                                                             (i.e. Electrical 1975, Plumbing 1980, Heating 1985, Roof 1990)                                                        

Does the Dwelling have 100% Copper Plumbing? :  Not Sure Yes No

Does the Dwelling have Circuit Breaker or Fuses? Circuit BreakersFuses  

If Renters Policy or Townhouse Condo Policy, amount of contents (personal belongings)                     coverage  needed:  

# of Bathrooms: 1 1.5 2 2.5 3 4+       # of Fireplaces: None 1 2 3 4+  

Garage type: NoneAttachedDetachedCarport Street Is it a 1, 2, 3 or 4 Car Garage?  

Type of Pool: NoneBelow GroundAbove GroundSpa/Jacuzzi Is the Pool Fenced? N/A YesNo  

Type of Roof Asphalt Shingle Cement Tile Spanish Tile (Clay) Wood Shingle Rock Slate Aluminum Steel Age of Roof  

Type of Air System: NoneCentralSwamp CoolerWall Unit Window  

Type of Security Alarm:  

Is Property Located in a Brush area? NoYes Distance from Brush : N/A < 150 Feet 150 to 200 Feet 200 to 500 Feet 500 to 1,000 Feet 1,000 Feet or more Not Sure  

Is Property Located near a Cliff or Shore Line? NoYes  

# of Claims last 5 yrs. None 1 2 3 4+ Type of Loss, Cause of Loss, Date and $ Amount:  

Are There Bars on the Windows? NoYes If so, are they the Quick Release Type? N/A YesNo  

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Earthquake Insurance:

Do you have Earthquake Insurance? NoYes Would you like a quote? NoYes  

If you wish to have an Earthquake Insurance Quotation "Only", please provide your policy's current Dwelling Coverage Limit:

Property Grade Level : Flat Gentle Steep but < 26% Greater than 26%

Type of Foundation : Concrete Slab Crawl Space w/Wood Perimeter Crawl Space w/Concrete Perimeter Post, Pier or Stilts

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Specialty Insurance:

Would you like a Flood Insurance Quotation?  No Yes

Would you like a Home Warranty Insurance Quotation? No Yes

For Jewelry, Art & Antique Coverage, please provide the description and current appraised $ amount for each item:

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Please include a valid email address, phone/fax number, how you'd prefer to be contacted and the best time and day. (Note: For a return quote leave a fax number or email address.)