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Personal
Information
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| First
Name |
|
Last Name |
|
| Address |
|
Suite / Apt |
|
| City |
|
State |
|
Zip
Code |
|
|
| Home
Phone |
|
Work Phone |
|
| Best
time to call |
|
E-mail |
|
|
|
Property
Information
Address
to be insured
|
| Property
Address |
|
Zip
Code |
|
| Stories |
#of Stories |
Year Built |
|
19xx
- 20xx |
|
| #
of Units in residence/building |
#of
Units |
Living Area |
|
Sq
Feet (Home
Only) |
| Full
Baths |
#
of full Baths |
Half Baths |
|
#
of half Baths |
|
| Fireplaces |
#
of fireplaces |
Garages |
|
|
| Kitchen quality |
|
Roof Type |
|
|
| $ Value of personal belongings/property
|
|
|
Current
Home Insurance Dwelling Coverage |
|
Claims in the
Last
5 Years |
|
|
|
| |
|
|
|
Your Floors
Floor
total must = 100% |
|
| Hardwood |
|
|
|
Vinyl |
|
|
|
Wall
to
Wall |
|
%
Average |
|
Parquet/Prego |
|
|
|
Wall
to
Wall |
|
%
Deluxe |
|
Slate |
|
|
|
|
Carpet
over wood |
|
%
Average |
|
Tile |
|
%
Average Quality |
|
Carpet
over wood |
|
%
Deluxe |
|
Tile |
|
%
Deluxe Quality |
|
| Marble |
|
Not
vinyl |
|
Brick |
|
|
|
| Terrazzo |
|
|
|
Stone |
|
|
|
|
Floor
total must = 100% |
|
|
Other property features or information
to include. |
|
How were
you referred |
|
|
| |
| By
clicking the Submit button
I have Reviewed the
Privacy
Statement and
the
Home
Insurance Disclosure Statement
and Understand that this
is only a quote for the
State of California, any
information and does not
constitute a binder of coverage or proof of Insurance
in any form, or does
it guarantee insurance.
All Coverage's are subject
to the terms and conditions contained in
the policy and endorsements.
I agree the above information
is true and factual.
Insurance will not
begin until I sign
and make a down payment. |
|
|
|
