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Homeowners, Rental & Condo Insurance Quote Form
First Name:
Last Name:
Email Address:
Home Phone:
Work Phone:
Alternate Phone:
Property Street Address:
City:
Ca
Zip:
Policy Type
Homeowners
Rental
Condo
Type of Residence
Apartment
Condo
Duplex
Single Family Home
Year Built
Square Feet of Living Area
Number of Stories
Garage Type:
Attached
Detached
Size of Garage - # of Cars:
1
2
3
4
Occupancy:
Primary
Seasonal
Secondary
Policy Deductible:
500
100
1500
2500
Roof Type:
Tile
Slate
Wood Shake
Shingles
Metal
Other
Age of Roof?
Number of Full Bathrooms
Number of 1/2 Bathrooms
Fireplace?
None
Wood
Gas
Swimming Pool/Spa/Hot Tub:
Yes
No
Floor Finish:
Hardwood
Tile
Linoleum
Carpet
# of Large Skylights:
# of Small Skylights:
Has The Dwelling Been Updated:
Yes
No
Description of Update/Work done:
Any Animals?:
Yes
No
How Many:
Type/Breed:
Losses in the past 3 years: (Date of loss, loss type, and amount of loss)
Earthquake Coverage:
Yes
No
What Insurance Company Do You Currently Have:
Allied AMCO
Fireman's Fund Premiere
First American Specialty
McGraw PSIC Standard
McGraw PSIC Preferred
Mercury
Safeco
Travelers
Other