General Information: First Name:* Last Name:* Street Address:* City:* State:* Zip Code:* Home Phone:* Work Phone: Fax: Email:* Current insurance company: Current policy expires: / / Home Information: Year Built ( 4 digit): Sq. Ft. of Living Area: Garage: Select No Yes, Attached Yes, Detached Number of cars garage built for: Select 1 2 3 4 Fireplace: Select 0 1 2 3 Breakers or fuses? Select Breakers Fuses Roof Type: Select Wood Shake Tile Concrete/Cement Fiber Cal-Shake/Permatek Cal-Shake/Cemwood Tar/Gravel Composition Shingles Metal Is the roof over 25 years old? Select Yes No Type of construction: Select Standard Refined Custom Central air: Select Yes No Smoke alarm: Select Yes No Burglar alarm: Select No Yes, central monitor Yes, local alarm Swimming Pool: Select No Yes, gated Yes, not gated Security bars on windows: Select Yes No Animals on premises: Select Yes No If there are animals on the premises list type/breed: Have you had any claims in the past 3 years? Select Yes No If yes explain: Is any business conducted on the premises? Select Yes No If yes explain: Have you had a bankruptcy, foreclosure, repossession or judgement over $1500 in the past 5 years? Select Yes No If yes explain: Do you have valuable or unusual property which you wish to insure under scheduled personal property coverage? Select Yes No If yes explain: Is the property located within 1000 feet of a fire hydrant? Select Yes No Is the property located within 5 miles of responding fire department? Select Yes No Is the property located in a brush area? Select Yes No Unsure Is the property located on a slope of 30% or more? Select Yes No Unsure Do you own one or more additional residential properties? Select Yes, rental Yes, vacation No If the home was built before 1960, when were the following updated? Electric: / / Plumbing: / / Roof: / / Is the home bolted to the foundation? Select Yes No Please remember, a policy can only be issued if your meet our underwriting requirements. Privacy Policy | Legal Agreement