EARTHQUAKE WORKSHEET
First Name:
Last Name:
Business Name:
Mailing Address:
Mailing City:
Mailing State:
California
Mailing Zip Code:
Phone Number:
Fax Number:
E-Mail Address:
PROPERTY INFORMATION
Property Address:
Property City:
Property State:
Select...AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming
Property Zip Code:
Occupancy Type:
Owner Tenant Vacant Owner & Tenant
Building Type:
House Condo - Contents Townhome Apartment Building Office Building Condo Assoc Complex High Rise Building Manufacturing Building
Year Built:
How Many Stories:
1 2 3 4 5 6 7 8 9 10 More Than 10 Stories
Total Square Footage of the Building:
How Many Units Are In The Building:
Garage Description:
No Carport - Garage Car Carport - Attached Car Carport - Detached Garage - Attached Garage - Detached Tuck Under Parking Above Ground Parking Below Ground Parking Parking Lot Street Parking
Construction Type:
Frame Masonry Veneer Masonry Superior
Foundation Type:
Piers Wood Stilts Posts - Pilings Basement Masonry Rubble Stone Non-Reinforced Concrete Craw Space - Concrete Perimeter Craw Space - Wood Perimeter Flat Slab-Poured Reinforced Concrete
Nature of Sub-Soil:
Sand Clay Rock Marsh Filled Land Unconsolidated Ground Natural Consolidated Ground
Topography:
Flat Cliff Terraced Steep Hill Gentle Hillside Under 100ft to Water Hillside Over 30 Degrees
Roof Type:
Tile Slate Metal Woodshake Composite Material
Roof Updated:
yes no
If Yes, Year Roof Updated:
Any Erosion in the Area?
Any Below Ground Parking?
Any Soft First Story or Tuck Under Parking?
Protection Distance:
1000 ft or less to a hydrant & 5 mi or less to a fire station Over 1000 ft to a hydrant & 5 mi or less to a fire station Over 5 & up to 10 mi to a fire station Over 10 mi to a fire station
Is the Building in the Brush Area?
yesno
Is there a Brush Hazard within (1) mile of the Building?
If yes, has the Brush been cleared by 250 feet from all sides of the Building?
Smoke Detectors:
Fire Extinguishers:
Electrical Updated:
yes, recently updated no
Circuit Breakers:
Heating - Air Conditioning, How Old?
Plumbing Updated:
If Yes, Year Plumbing Updated:
Copper Plumbing:
Automatic Sprinklers:
None Partial full
Fire Alarm:
None Local
Earthquake Retrofitted or Bolted:
Yes No, Building is Not Bolted Yes, Recently Bolted or Retrofitted for EQ
Current Insurance Company:
Losses-Claims in the last 5 years:
None One Two Three Four Five
If Yes, Date, Amount Paid and Description of each Loss-Claim
COVERAGE INFORMATION
Building Coverage:
Other Structures Coverage:
Contents Property Coverage:
Loss of Use Coverage:
Earthquake Deductible:
5% 7.5% >10% 15% 20% 25% 30%
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