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:

Property Zip Code:

Occupancy Type:

 

Building Type:

 

Year Built:

How Many Stories:

Total Square Footage of the Building:  

How Many Units Are In The Building:

Garage Description:

 

Construction Type:

 

Foundation Type:

 

Nature of Sub-Soil:

 

Topography:

 

Roof Type:

 

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:

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:

Circuit Breakers:

yes no

Heating - Air Conditioning, How Old?

Plumbing Updated:

yesno

If Yes, Year Plumbing Updated:

Copper Plumbing:

yes no 

Automatic Sprinklers: 

Fire Alarm:

Earthquake Retrofitted or Bolted: 

Current Insurance Company:

Losses-Claims in the last 5 years: 

 

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:

 

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Thank you for your interest.