FAST AND EASY HOMEOWNERS INSURANCE PROPOSAL FOR BUSY PEOPLE

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FIRST NAMEFirst Name

LAST NAME

Dateof appointment

Property Addressyour full name

Unit #your full name

Cityyour city

STATE

CA

ZIPZIP

Countyyour county

PHONECELL PHONE#

Emaila valid email

Email again for Accuracya valid email

Married ?

YesNo

Birthdate of OwnerBirth driver 2

Currently Insured ?

YesNo

Current Insurance Company name ?your full name

What is your Occupation? (Also list your spouses occupation if married.)

Dwelling Information

Property Type

Property TypeSingle Family HomeDuplex- I live in oneDuplex- Both rented

Foundation

Foundation Type ?SlabCrawlspaceBasementOther

Garage

Garage Type ?AttachedDetachedCarportNone

Construction

Construction Type ?FrameBrick/VeneerStoneOther

Roof Type

Roof Type ?ShingleWood ShakeTar/GravelRockSpanish TileMetalOther

Stories

Number of Stories ?1 Story1.5 Story2 Story3 Story

Bathrooms

Bathrooms ?1 1.5 22.5 3

Fully Built

House Fully Built ?YesNo

If Not Fully Built... Mth / Yr to be completed and details?your full name

Claims Last 3 years?

YesNo

Describe all claims & amounts last 3 years?

Animals or Pets ?

YesNo

Describe any pets that you have.your full name

Plumbing Type ?pick one!

Plumbing Type ?CopperGalvanizedMixedOther

Heat Type

Select HeatingGasElectricCoalWood BurningOther

Circuit Breakers ?

Circuit Breakers ?Circuit BreakersFuses

Pool ?

YesNo

Alarm Service?

YesNo

Jacuzzi ?

YesNo

Fireplace ?

YesNo

Brush Area ?

YesNo

PLEASE DESCRIBE IN DETAIL ANY SPECIAL FEATURES, ADDITIONS, OR MODIFICATIONS TO THE HOUSE.more details

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DESCRIBE ANY IN HOME BUSINESS OR ANY SPECIAL COVERAGE REQUESTS SUCH AS HIGH LIABILITY LIMITS, EXPENSIVE JEWELRY, PAINTINGS, GUNS, RUGS, SILVERWARE, etc. LIST THEM HERE. If there is no additional exposure type "NONE"more details

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