Pay by credit cards to buy Insurance.
Are you now insured or have you been in the past 30 days?
Yes No
Have you had any insurance claims or losses in the past 3 years,regardless of fault?
Email address
Street Address
City
Country
State / ZIP
Select AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Current Policy Expiration Date:
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 2003 2004 2005 2006
Property Information
Fire Information
Currenly insured? Yes No
If insured, what company do you have insurance with
How much are you paying annually? $ Property Occupancy: Owner Occupied Tenant Occupied Renter Secondary
Construction: Wood Frame w/Stucco Wood Frame w/Wood Siding BrickSteel/Aluminum Frame
Number of Stories: 11.522.534+Townhouse/CondoApartmentTri-Level
Please list any Renovations and year of (Examples - Electrical 1990, Plumbing 1987, Heating 1982, Roof 1993)
Does the Dwelling have 100% Copper Plumbing? : Not Sure Yes No
Does the Dwelling have Circuit Breaker or Fuses? Circuit BreakersFuses
If Renters Policy or Townhouse Condo Policy, amount of contents (personal belongings) coverage needed:
# of Bathrooms: 11.522.534+ # of Fireplaces: None1234+
Garage type: NoneAttachedDetachedCarport Street Is it a 1, 2, 3 or 4 Car Garage?
Type of Pool: NoneBelow GroundAbove GroundSpa/Jacuzzi Is the Pool Fenced? N/A YesNo
Roof Type: Tile Slate Metal Wood shake Other Age of Roof
Type of Air System: NoneCentralSwamp CoolerWall Unit Window
Type of Security Alarm:
Is Property Located in a Brush area? NoYes Distance from Brush : N/A < 150 Feet 150 to 200 Feet 200 to 500 Feet 500 to 1,000 Feet 1,000 Feet or more Not Sure
Is Property Located near a Cliff or Shore Line? NoYes
Earthquake Insurance Coverage:
Do you have Earthquake Insurance? NoYes Would you like a quote? NoYes
If you wish to have an Earthquake Insurance Quotation "Only", please provide your policy's current Dwelling Coverage Limit:
Property Grade Level : Flat Gentle Steep but < 26% Greater than 26%
Type of Foundation : Concrete Slab Crawl Space w/Wood Perimeter Crawl Space w/Concrete Perimeter Post, Pier or Stilts
Additional Flood or jewelry and Art & Antiques Insurance:
Would you like a Flood Insurance Quotation? No Yes
Would you like a Home Warranty Insurance Quotation? No Yes
For Jewelry, Art & Antique Coverage, please provide the description and current appraised $ amount for each item:
Requested Coverage
Residence Accessories (check all that apply)
Covered Patio/Deck
Tennis Court
Uncovered Patio/Deck
Swimming Pool
