HOMEOWNER WORKSHEET

 

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:

 

Number of Fireplaces:

Garage Description:

 

Year Built:

Date You Purchased the Home:

How Many Stories:

Total Square Footage of the Dwelling:  

Construction Type:

 

Roof Type:

 

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:

 

Foundation Type:

 

Protection Distance:

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:

Fire Alarm:

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: 

 

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):

Policy Deductible:

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.