Your Name:
Property Address:
City:
State:	MUST be California!
Zip/Postal:
E-Mail (REQUIRED):
E-Mail (again for accuracy):
Phone:
Fax (optional):
Dwelling Information
Year Home Built:
Home Square footage:
Number of units:	1 family Duplex
Type foundation:	Slab Crawlspace over slab Pier & Post Other (list in remarks)
Type Roof:	Shingle Wood Shake Tar/Gravel Spanish Tile
Number of stories:	One 1.5 Two Three
Do you own animals or pets?	Yes No
If yes, list type/for dogs, list breed:
Currently Insured?	Yes No
Name of Carrier & how long insured?
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

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