Single Location Insurance Quote

13437 VENTURA BLVD., SUITE 205,
SHERMAN OAKS, CA 91423, USA.
Phone (818) 906-1454 Fax (818) 906-2682

Please complete the following general questionnaire. Our professional, courteous staff will contact you regarding your quote. Or call us at 1 (800) 779-PARS

General Information

Insured's Name
Phone Number
Fax Number
Email Address
Insured is
Business Name

Location

Property Address

City

Zip Code

No. of Stories
No. of Units
SQ. Footage
Year Built

Pool

Garage

Year Remodeled

Plumbing

Electrical

Roof Age

Material

Loss History

Prior carrier and loss history for the past three years

From Mo. Yr. To Mo. Yr.

Company name

Policy number

Claims and Losses:

Number Amount

Cancelled or Non-renewed

Reason

Desired Coverages

Liability Limit
Building
Loss of Rent
Deductible

If you have already been given a quote, entering the figure here may help you get a better deal

How did you hear about us

You can e-mail this form to us by pressing the submit button above. To fax the information, please print this form and complete the required information and fax to (818) 906-2682.

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