LANDLORD 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 Bedrooms:

Number Of Bathrooms:

Number of Fireplaces:

Garage Description:

 

Year Built:

Date You Purchased Home:

How Many Stories:

If Two Stories, Ground Floor Square Footage:  

Total Square Footage of Your Dwelling:  

Construction Type:

 

Roof Type:

 

Roof Updated:

yes no 

If Yes, Year Roof was Updated:

Does The Dwelling Have A Pool?

yes no 

If Pool, Is It Fenced?

yes no 

If Pool, Is There A Diving Board?

yes no 

If Pool, Is There A Slide?

yes no 

Property Topography:

 

Foundation Type:

 

Protection Distance:

Is Dwelling in the Brush?

yes no 

Is there a Brush Hazard within (1) mile of Your Dwelling:

yes no 

If yes, has the Brush been cleared by 250 feet from all sides of Your Dwelling?

yesno 

Smoke Alarm:

yesno

Fire Extinguisher:

yesno 

Deadbolts:

yesno

Electrical Updated:

Circuit Breakers:

yes no

Copper Wiring:

yes no

Heating - Air Conditioning, How Old?:

Heating - Air Conditioning, Thermostatically Controlled?:

yesno 

Energy Source: 

Heating - Air Conditioning, Central?

yes no 

Plumbing Updated:

yesno

If Yes, Year Plumbing was Updated:

Copper Plumbing:

yes no 

Interior Automatic Fire Sprinklers: 

Theft Alarm:

Fire Alarm:

Earthquake Zone:

Earthquake Retrofitted: 

 

Fire District:

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 Value (Coverage A):

 

Specific Structures (Coverage B):

Personal Property (Coverage C):

Loss of Use (Coverage D):

Premise Liability (Coverage E):

Liability Type:

Policy Deductible:

If EarthQuake Insurance is Requested, Select Deductible Percentage %:

 

Dwelling Replacement Cost Coverage:

yesno 

Questions or Comments
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Thank you for your interest.