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Personal Information * Last Name * First Name Street Address City State Zip Code Phone Number Alternate Telephone Fax Number * Email Address Property Information Property Street Address City State Zip Code How many units are in the building? How many units in the building are vacant? Year Built What date was the property purchased? What is the construction type? -Select- Brick Stone Frame Masonry Superior Log Cabin Frame-Stucco Masonry Veneer How many stories is it? If two stories, what is the ground floor square footage? What is the total square footage of the building? What foundation type? -Select- Crawl Space Piers/Pilings/Stilts Slab on Grade Unfinished Basement Walkout Basement Wood Foundation Basement If structure is located in a flood zone, what is the distance to body of water? -Select- Do not live in flood zone Less than 100 ft 100-500 ft 500-1000 ft More than 1000 ft Garage Description -Select- No Carport-Garage Car Carport Attached Car Carport Detached Garage Attached Garage Detached Tuck Under Parking Above Ground Parking Below Ground Parking Parking Lot Street Parking What type of roof covering? Was the roof updated? Yes No If yes, what year? Does the building have a pool? Yes No If yes, is it fenced? Yes No If there is a pool, is there a diving board? Yes No If there is a pool, is there a slide? Yes No What is the distance to fire protection? -Select- 1000 ft or less to hydrant and 5 mi or less to fire station Over 1000 ft to hydrant and 5 MI or less to fire station Over 5 and up to 10 MI to fire station Over 10 MI to fire station Is the building in the brush? Yes No Is there a brush hazard within one mile of the building? Yes No If yes, has the brush been cleared by 250 feet from all sides of the building? Yes No Is there a smoke alarm? Yes No Is there a fire extinguisher? Yes No Are there deadbolts? Yes No Is the electrical updated? Yes No Are there circuit breakers? Yes No Does the electrical circuit box have copper wiring? Yes No How old is the heating/ air conditioning? Is the heating / air conditioning thermostatically controlled? Yes No What is the energy source? -Select- Gas Electrical What is the heating system? -Select- None Heat Pump Electric Gas Oil What is the cooling system? -Select- None Central Air Evaporative Cooler Has the plumbing been updated? Yes No Is the plumbing copper? Yes No Does the building have interior automatic fire sprinklers? Yes No Is there a theft alarm? Yes No Is there a fire alarm? Yes No What is the earthquake zone? Has it been earthquake retroffited? -Select- Not required - home built after 1975 Yes recently been bolted - retrofitted for EQ No What is the fire district? Are there dogs on the property? Yes No If yes, how many and what is the breed of each dog? Are there any other pets or animals on the property? Yes No If yes, how many and what is the description of each? Current Coverage Information Current Insurance Company Expiration Date Were there any losses or claims in the last 5 years? Yes No If yes, what is the date, amount paid and description of each loss or claim? Desired Coverage Information Dwelling Amount - Coverage A Other Structures - Coverage B Business Property - Coverage C Loss of Use - Coverage D Premise Liability - Coverage E -Select- 100,000 300,000 500,000 Policy Deductible -Select- 100 250 500 750 1000 2500 5000 If earthquake insurance is requested, select deductible percentage % -Select- None 10% 15% 20% 25% 30% Do you want building replacement cost coverage? Yes No Best Time To Contact You Please let us know the best time to call and discuss your quote. Morning Afternoon Evening Anytime Or Specify Other: Before submitting, type in required validation security code: l3jv96