First Name:

Last Name:

Mailing Address:

Mailing City:

Mailing State:

Mailing Zip Code:

Phone Number:

Fax Number:

E-Mail Address:



Property Address:


Property City:

Property State:


Property Zip Code:

How Many Units In The Building?

How Many Units In The Building Are Vacant?

Year Built:

Date You Purchased The Property:

Construction Type:


How Many Stories:

If Two Stories, Ground Floor Square Footage:  

Total Square Footage of The Building:  

Is There A Basement?

yes no 

Garage Description:


Roof Type:


Roof Updated:

yes no 

If Yes, Year Roof was Updated:

Does The Dwelling Have A Pool?

yes no 

If Pool, Is It Fenced?

yes no 

If Pool, Is There A Diving Board?

yes no 

If Pool, Is There A Slide?

yes no 

Protection Distance:

Is The Building in the Brush?

yes no 

Is there a Brush Hazard within (1) mile of The Building?

yes no 

If yes, has the Brush been cleared by 250 feet from all sides of The Building?

yes no 

Smoke Alarm:


Fire Extinguisher:




Electrical Updated:

Circuit Breakers:

yes no

Does The Electrical Circuit Box Have Copper Wiring?

yes no

Heating - Air Conditioning, How Old?:

Heating - Air Conditioning, Thermostatically Controlled?:


Energy Source: 

Heating - Air Conditioning, Central?

yes no 

Has The Plumbing Been Updated?

yes no

If Yes, Year Plumbing was Updated:

Copper Plumbing:

yes no 

Does the Building Have Interior Automatic Fire Sprinklers? 

Theft Alarm:

Fire Alarm:

Earthquake Zone:

Earthquake Retrofitted: 


Fire District:

Current Insurance Company:

Any Dogs on the Property:

yes no

If Yes, Number & the Breed of Each Dog:


Any Other Pets-Animals on the Property:

yes no 

If Yes, Number & Description of Each Pet-Animal:

Losses-Claims in the last 5 years: 


If Yes, Date, Amount Paid & Description of Each Loss-Claim





Dwelling Amount (Coverage A):


Other Structures (Coverage B):

Business Property (Coverage C):

Loss of Use (Coverage D):

Premise Liability (Coverage E):

Policy Deductible:

If Earthquake Insurance is Requested, Select Deductible Percentage %:


Building Replacement Cost Coverage: 


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Thank you for your interest.