Your Personal Data

Your Name:
Property Address:
City:
State:	CALIFORNIA
Zip:
E-Mail (REQUIRED):
Phone:
Fax (optional):
Many Carriers Now Use Credit Scoring For Rates and Discounts. How would you honestly rate your credit strength & past payment history?	Perfect Fair Poor No Past Credit
Dwelling Information
Year Home Built:
Home Square footage:
Is this Builder's Risk? (new home constr.)	NO YES
Month/Year home to be complete:
Number of units: (We can write owner occupied homes up to 4 units)	1 family Duplex 3 Units 4 Units
Construction Type:	Frame Masonry/CBS Fire resistive
Type foundation:	Slab Crawlspace over slab Pier & Post Other (list in remarks)
Type Roof:	Shingle Wood Shake Tar/Gravel Spanish Tile Metal Other
Number of stories:	One 1.5 Two Three
Do you own animals or pets?	Yes No
If yes, list type/for dogs, list breed:
Are You Near Brush Area?	Yes No
# of feet to nearest fire hydrant:	# of miles to nearest fire station:
Currently Insured?	Yes No
Prior Claims?	Yes No
Describe claims in detail:
Plumbing type:	Copper Galvanized Mixed (Copper/Galvanized)
Circuit Breakers or fuses?	Breakers Fuses

# Bedrooms:		# Bathrooms:
# Fireplaces:		# Chimneys:
Special features (i.e., deck, air conditioning, alarm systems, pool, etc.)
Coverages:
Dwelling Cov. $		Contents $
Liability Cov. $		Deductible $ ($250, $500, $1,000, etc.)
Comments/Remarks (describe any scheduled jewelry, in-home business, or other special coverages needed here):
Send my quotation via:		E-Mail Fax Regular Mail Call Me By Phone

Thank you for filling out this form COMPLETELY! We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy. Yes, I Agree. Please Send Me the Quote NOW!