Your Name:
Property Address:
City:
State:	MUST be California!
Zip/Postal:
E-Mail (REQUIRED):
E-Mail (again to verify):
Phone (Optional):
Fax (Optional):
Year Home Built:
Home Square footage:
Current H/O Carrier:
Current H/O Cov. Amt.	$
Is Home Retrofit by Licensed Contractor?	Yes No
Quake coverage now? (Required Field)	Yes No
Current Quake Carrier (type none if no coverage): (Required Field)
Number of units:	1 family Duplex 3 Family 4 Family
Occupancy:	Owner Occupied Rental
Type Construction:	Wood Frame Wood w/stucco Brick (NOT ELIGIBLE!)
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
Slope (On hill?):	None Gentle (>20 degr.) Steep Stilts/cliff
Comments/Remarks:
Send my quotation via:	E-Mail Fax Regular Mail Only

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