Homeowners Insurance

For California residents only.

After you've completed this form, click on the SUBMIT button to receive your free homeowner insurance quote. You'll be given an opportunity to specify U.S. Postal Service, e-mail or fax. Or phone (760) 644-0351.

Customer Information
Name
E-mail
Street address
City
County
State
Zip Code
Home Phone
Work Phone
FAX

Address of Property (if different from above):
Address
City
County
State
ZipCode

Home Building Description
Number of families:	Age 55 & Retired	Inside City Limits?	Year Built	Central & Alarm Systems (Select all that apply)
	Yes No	Yes No		Smoke Alarms Local Burglar Alarm Fire Extinguisher Central Station Burglar Alarm Dead Bolts Central Station Fire Alarm Local Fire Alarm Interior Sprinkler System Vacuum System Intercom - connects all rooms

More Property Information
Home Style	-- select -- 1 story - Ranch 1.5 story - Cape 1.65 story - Bi-level 1.75 story - Tri-level 2 story - Colonial 2 story - Victorian Standard 2 story - Victorian Ornate End Unit - Townhouse Center Unit - Townhouse
Hillside Construction	-- select -- None Low (15-29%) Moderate (30-44%) Steep (45-60%)
Type of Foundation	-- select -- Crawl Space (built prior to 1961) Slab (built after 1961) Basement (unfinished) Basement (finished)
Garages:	1 Car        2 Cars      3+ Cars Attached  Detached  Built-In  Carport
Kitchen:	-- select -- Standard Kitchen Custom Kitchen Deluxe Kitchen
Bathrooms:	-- select -- 1 Bathroom 1 1/2 Bathrooms 1 3/4 Bathrooms 2 Bathrooms 2 1/2 Bathrooms 2 3/4 Bathrooms 3 Bathrooms 3 1/2 Bathrooms 3 3/4 Bathrooms 4 Bathrooms
Attached Porch:	-- select -- None Small Open Porch Medium Open Porch Large Open Porch Small Closed Porch Medium Closed Porch Large Closed Porch
Attached Wood Decks:	-- select -- None Small Decks Medium Decks Large Decks Small Custom Decks Medium Custom Decks Large Custom Decks
Greenhouse:	-- select -- None Small Greenhouse Medium Greenhouse Large Greenhouse
Square Footage :
Finished Attic (%) :
Cathedral Ceiling (%) :
Breezeways:
Balconies:
Fireplaces:

Even More Property Information
Exterior Walls (must equal 100%):	% Stucco on Frame % Wood Siding % Wood Shake % Wood Shingle % Clapboard % Aluminum Siding	% Solid Brick % Solid Stone % Brick Veneer % Concrete Block % Stucco on Block % Other (See Comments)
Interior Wall Coverings (must equal 100%):	% Paint (only) % Average Paper % Ornate Paper % Stone % Mirrors % Grass Paper % Book Case % Marble Tile % Plywood Paneling % Millwork	% Terrazzo % Heavy Wood % Knotty Pine % Carpet % Ceramic Tile % Deluxe Tile % Stucco % Cork % Brick % Other (See Comments)
Flooring (must equal 100%):	% Hardwood % Avg. Carpet on Hardwood % Luxury Carpet/Hardwood % Wall-Wall Carpet, Avg. % Wall-Wall Carpet, Luxury % Parquet % Tile % Deluxe Tile	% Vinyl % Terrazzo % Flagstone % Slate % Stone % Brick % Plank % Marble
Roof:	-- select -- Asphalt/Fiberglass/Comp Shingles Wood Heavy Wood Shake Tile (clay,concrete) Tar & Gravel (built-up) Slate Other (See Comments)
Heating:	-- select -- Gas Electric
Air Conditioning:	-- select -- None A/C only A/C Same ducts as heat A/C Separate ducts

Requested Coverages
Home currently insured for: (This is NOT the purchase price)	Liability	Deductible	Earthquake Cov. Wanted?
	-- select -- $100,000 $300,000 $500,000 $1,000,000	-- select -- $500 $1,000 $2,500 $5,000	Yes No

Do you have any Jewelry, Fine Arts, Sporting Equipment or Collections which may need special "ALL RISK" Coverage?

Underwriting Information
Current Insurance
Expiration Date
Breed of Dogs?
Losses within the last 5 years?

Reporting Method
How would you like to receive your free Homeowner Insurance quote?	U.S.Postal E-mail Fax

 

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