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? yes no  Any Below Ground Parking? yes no  Any Soft First Story or Tuck Under Parking? yes no  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? yesno  If yes, has the Brush been cleared by 250 feet from all sides of the Building? yesno  Smoke Detectors: yesno  Fire Extinguishers: yesno  Electrical Updated: yes, recently updated no  Circuit Breakers: yes no Heating - Air Conditioning, How Old? Plumbing Updated: yesno If Yes, Year Plumbing Updated: Copper Plumbing: yes no  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%   Please press the Submit Button ONCE. Then wait for online confirmation of your request. Thank you for your interest.