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First Name: Last Name: Phone Number: Fax Number: E-Mail Address:    PROPERTY INFORMATION   Property Address:   Property City: Property State: California Property Zip Code: Dwelling Type: House Condo Townhome    Number of Fireplaces: Garage Description: No Carport - Garage 1 Car Carport - Attached 2 Car Carport - Attached 1 Car Carport - Detached 2 Car Carport - Detached 1 Car Garage - Attached 2 Car Garage - Attached 3 Car Garage - Attached 1 Car Garage - Detached 2 Car Garage - Detached 3 Car Garage - Detached   Year Built: Date You Purchased the Home: How Many Stories: 1 2  Total Square Footage of the Dwelling:   Construction Type: Frame Masonry Veneer Masonry Superior   Roof Type: Tile Slate Metal Woodshake Composite Material   Does The Dwelling Have A Pool? yes no  If Yes, Is It Fenced? yes no  If Yes, Is There A Diving Board or Slide? yes no  Property Topography: Flat Land Gentle HillsideSteep HillsideCantilevered / Stilts  Foundation Type: Concrete Slab Poured Perimeter Brick Rubble Stone Crawl SpaceMasonry   Protection Distance: Under 1000 ft to hydrant & less than 5 mi to fire station Over 1000 ft to hydrant & less than 5 mi to fire station Over 5 mi to a fire station  Is Dwelling in Brush? yes no  Smoke Alarm: yesno Fire Extinguisher: yesno  Deadbolts: yesno Circuit Breakers: yes no Heating - Air Conditioning, Central? yes no  Copper Plumbing: yes no  Theft Alarm: None Local Central  Fire Alarm: None Local Central Current Insurance Company: Expiration Date of Current Insurance Policy: Any Dogs on the Property: yes no If Yes, Number & the Breed of Each Dog:   Any Other Pets-Animals on the Property: yes no  If Yes, Number & Description of Each Pet-Animal: Losses-Claims in the last 5 years:  None One Two Three Four Five   If Yes, Date, Amount Paid & Description of Each Loss-Claim    COVERAGE INFORMATION   Dwelling Amount (Coverage A):   Other Structures (Coverage B): Personal Property (Coverage C): Loss of Use (Coverage D): Premise Liability (Coverage E): $300,000 $100,000 $500,000  Policy Deductible: 100 250 500 750 1000 2500 5000  Dwelling Replacement Cost Coverage: yesno  Contents Replacement Cost Coverage: yesno Would you like a separate EarthQuake Insurance Quote? yesno Questions or Comments to help the Agent:   Please press the Submit Button ONCE. Then wait for online confirmation of your request. Thank you for your interest.