* =Required Fields
Personal Information
*
First name
*
Last name
*
Gender
Select
male
female
Occupation
Age
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16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
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81
82
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84
85
86
87
88
89
90
*
Home phone
*
Business phone
*
Marital status
Select
married
unmarried
divorced
*
Email address
Property Address
*
Street
*
City
State
*
Zip code
County
Select
Alameda County
Alpine County
Amador County
Big Sur Region
Butte County
Calaveras County
Central Coast
Central Valley
Colusa County
Contra Costa County
Del Norte County
El Dorado County
Fresno County
Glenn County
Humboldt County
Imperial County
Inyo County
Kern County
Kings County
Lake County
Lake Tahoe
Lassen County
Los Angeles County
Madera County
Marin County
Mariposa County
Mendocino County
Merced County
Modoc County
Mono County
Monterey County
Napa County
Nevada County
Northern California
Orange County
Placer County
Plumas County
Riverside County
Sacramento County
San Benito County
San Bernardino County
San Diego County
San Francisco County
San Joaquin County
San Luis Obispo County
San Mateo County
Santa Barbara County
Santa Clara County
Santa Cruz County
Shasta County
Sierra County
Sierra Nevada
Silicon Valley
Siskiyou County
Solano County
Sonoma County
Southern California
Stanislaus County
Sutter County
Tehama County
Trinity County
Tulare County
Tuolumne County
Ventura County
Wine Country
Yolo County
Yuba County
About your home
*
No. of bathrooms
Select
none
1
2
3
4
5
*
no. of fireplaces
Select
none
1
2
3
4
5
*
No. of units
Select
condo
single family residence
duplex
triplex
fourplex
5 or more
*
living sq. footage
*
Year built
*
number of levels
Select
1
2
3
4
5
*
Swimming pools
Select
No
Yes
*
No. of car garage
Select
none
1
2
3
4
5
*
Spa
Select
No
Yes
Attached
*
Heating
Select
none
central
wall furnace
Detached
*
A/C
Select
No
Yes
Built-in
*
Roof type
Select
composition shingle
wood shakes
spanish tile
concrete/cement-fiber tile
rock
other
*
Deck
Select
No
Yes
*
Porch
Select
No
Yes
Construction type
Select
Frame
Brick/Masonry
Log
Adobe
Other
*
Roof age
Select
1-10 years
11-20 years
over 20 years
*
exterior type
Select
wood siding
stucco on frame
stucco on masonry
paint on masonry
solid brick
other
*
Foundation
Select
slab
raised
Coverage Limits
*
Liability requested
Select
$100,000
$300,000
$500,000
$1,000,000
Deductible
Select
500
750
1000
1500
2500
5000
Dwelling
Personal property
Loss of use
Discounts
*
Smoke detector
Select
No
Yes
*
Sprinkler coverage
Select
not applicable
partial
full (attic, closets, garage)
*
Auto insurance company
Select
farmers
other
*
Burglar alarm
Select
No
Yes
*
Type of alarm
Select
not applicable
connected to central station
rings out locally
*
Non-smoker discount
Select
No
Yes
Insurance Information
Prior/current carrier
No. of claims (in last 3 years)
1. Type of claim
Amount of claim
2. Type of claim
Amount of claim
3. Type of claim
Amount of claim
Comments
*
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