First Name: |
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Last Name: |
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Phone Number: |
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Fax Number: |
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E-Mail Address: |
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PROPERTY INFORMATION |
Property Address: |
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Property City: |
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Property State: |
California |
Property Zip Code: |
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Dwelling Type: |
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Number of Fireplaces: |
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Garage Description: |
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Year Built: |
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Date You Purchased the Home: |
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How Many Stories: |
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Total Square Footage of the Dwelling: |
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Construction Type: |
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Roof Type: |
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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: |
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Foundation Type: |
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Protection Distance: |
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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: |
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Fire Alarm: |
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Current Insurance Company: |
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Expiration Date of Current Insurance Policy: |
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Any Dogs on the Property: |
yes no |
If Yes, Number & the Breed of Each Dog: |
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Any Other Pets-Animals on the Property: |
yes no |
If Yes, Number & Description of Each Pet-Animal: |
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Losses-Claims in the last 5 years: |
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If Yes, Date, Amount Paid & Description of Each Loss-Claim |
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COVERAGE INFORMATION |
Dwelling Amount (Coverage A): |
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Other Structures (Coverage B): |
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Personal Property (Coverage C): |
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Loss of Use (Coverage D): |
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Premise Liability (Coverage E): |
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Policy Deductible: |
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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: |
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Please
press the Submit Button ONCE.
Then wait for online confirmation of your request.
Thank you for your interest.
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