Basic Address Information
 

Name
Address
City	Ca.			Zip

 
 

Please supply either a Daytime or Evening Phone Number & best time to call.
Day Time Number:
Evening Number:
Best Time To Call	Select MorningAfternoon Evening
E-mail:
Marital Status	Select SingleMarried Divorced SeparatedWidowed

Policy Type	Primary SecondaryRental
Property Zip Code
Dwelling Type	SelectHouseCondominium TownhouseMobile Home
# of Units		# of Stories
Year Built		Square Feet
Construction	SelectFrameBrick / VeneerStone / Masonry	Foundation Type	SelectSlabRaised
Type of Roof	SelectWood ShakeAshalt/CompositionTile	Last Replaced
Plumbing	SelectGalvanizedCopper	Last Update
Electrical System	SelectFuses Circuit Breaker	Last Update
Alarm	Select Local Central
Heating	SelectForced AirWall	Last Update
Central Air	Select Yes No
# of Fireplaces
# of Bathrooms
Garage	Select Attached DetachedNone	# of Car Garage
Swimming Pool	Yes No
Current Earthquake Damage

Prior Losses Past 3 Years	Yes No
Age of oldest owner

Any Smokers	Select Yes No
Deadbolts, Smoke Alarms & Fire Extinquishers	Select Yes No
Deductible

 
 

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