Homeowners Quote

Homeowners Quote Request

Your Information

Last Name*

First Name*

Email Address*

Street Address*

City*

State*

Zip Code*

Phone Number*

Alternate Phone

Birth Date*

Property Information

Property Street Address

City

State

Zip Code

Dwelling Type

Number of Bedroms

Number of Bathrooms

Number of Fireplaces

How many porches or decks are there?

What year was it built?

What date was the property purchased?

What is the construction type?

How many stories is it?

If two stories, what is the ground floor square footage?

Total square footage

What is the property's topography?

What foundation type?

If structure is located in a flood zone, what is the distance to body of water?

Garage Description

What type of roof covering?

Was the roof updated? Yes No

If yes, what year?

Does the building have a pool? Yes No

If yes, is it fenced? Yes No

If there is a pool, is there a diving board? Yes No

If there is a pool, is there a slide? Yes No

What is the distance to fire protection?

Is the building in the brush? Yes No

Is there a brush hazard within one mile of the building? Yes No

If there is a pool, is there a slide? Yes No

Is there a smoke alarm? Yes No

Is there a fire extinguisher? Yes No

Are there deadbolts? Yes No

Is the electrical updated? Yes No

Are there circuit breakers? Yes No

Does the electrical circuit box have copper wiring? Yes No

Is the heating / air conditioning thermostatically controlled? Yes No

How old is the heating/ air conditioning?

What is the energy source?

What is the heating system?

What is the cooling system?

Has the plumbing been updated? Yes No

Is the plumbing copper? Yes No

Does the building have interior automatic fire sprinklers? Yes
No

Is there a theft alarm? Yes No

What is the earthquake zone?

Has it been earthquake retroffited?

What is the fire district?

Are there dogs on the property? Yes No

If yes, how many and what is the breed of each dog? (250 chars left)

Are there any other pets or animals on the property? Yes No

If yes, how many and what is the description of each? (500 chars left)

Current Coverage Information

Current Insurance Company

Expiration Date (DD/MM/YYYY)

Were there any losses or claims in the last 5 years? Yes
No

If yes, what is the date, amount paid and description of each loss or claim? (500 chars left)

Desired 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

If earthquake insurance is requested, select deductible percentage %

Do you want building replacement cost coverage? Yes
No

Do you want contents replacement cost coverage? Yes
No

Please let us know the best time to call and discuss your quote. Morning
Afternoon
Evening
Anytime

Questions or Comments (1000 chars left)

Please type what you see

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