First Name: |
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Last Name: |
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Mailing Address: |
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Mailing City: |
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Mailing State: |
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Mailing Zip Code: |
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Phone Number: |
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Fax Number: |
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E-Mail Address: |
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PROPERTY INFORMATION |
Property Address: |
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Property City: |
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Property State: |
California |
Property Zip Code: |
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How Many Units In The Building? |
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How Many Units In The Building Are Vacant? |
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Year Built: |
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Date You Purchased The Property: |
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Construction Type: |
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How Many Stories: |
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If Two Stories, Ground Floor Square Footage: |
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Total Square Footage of The Building: |
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Is There A Basement? |
yes no |
Garage Description: |
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Roof Type: |
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Roof Updated: |
yes no |
If Yes, Year Roof was Updated: |
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Does The Dwelling Have A Pool? |
yes no |
If Pool, Is It Fenced? |
yes no |
If Pool, Is There A Diving Board? |
yes no |
If Pool, Is There A Slide? |
yes no |
Protection Distance: |
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Is The Building in the Brush? |
yes no |
Is there a Brush Hazard within (1) mile of The Building? |
yes no |
If yes, has the Brush been cleared by 250 feet from all sides of
The Building? |
yes no |
Smoke Alarm: |
yesno |
Fire Extinguisher: |
yesno |
Deadbolts: |
yesno |
Electrical Updated: |
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Circuit Breakers: |
yes no |
Does The Electrical Circuit Box Have Copper Wiring? |
yes no |
Heating - Air Conditioning, How Old?: |
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Heating - Air Conditioning, Thermostatically Controlled?: |
yesno |
Energy Source: |
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Heating - Air Conditioning, Central? |
yes no |
Has The Plumbing Been Updated? |
yes no |
If Yes, Year Plumbing was Updated: |
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Copper Plumbing: |
yes no |
Does the Building Have Interior Automatic Fire Sprinklers? |
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Theft Alarm: |
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Fire Alarm: |
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Earthquake Zone: |
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Earthquake Retrofitted: |
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Fire District: |
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Current Insurance Company: |
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Any Dogs on the Property: |
yes no |
If Yes, Number & the Breed of Each Dog: |
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Any Other Pets-Animals on the Property: |
yes no |
If Yes, Number & Description of Each Pet-Animal: |
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Losses-Claims in the last 5 years: |
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If Yes, Date, Amount Paid & Description of Each Loss-Claim
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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: |
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If Earthquake Insurance is Requested, Select Deductible Percentage %: |
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Building Replacement Cost Coverage: |
yesno |
Please
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Then wait for online confirmation of your request.
Thank you for your interest.
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