Condo Insurance Quote Request
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First Name
*
:
Last Name
*
:
Property Street Address
*
:
Apartment Number/ Unit:
City
*
:
State: California
Zip Code
*
:
Home Telephone
*
:
Work Telephone:
Fax Telephone:
Email Address:
Martial Status
*
:
Please Select
Single
Married
Occupation:
Prior Insurance company
Expiration:
Example 08/20/1970
Property Information
Is the property occupied by :
Owner or Tenant
Type of Dwelling
Please Select One
Condo
Townhouse
Year Built :
Square Feet:
# of
Families
at residences:
Years at residence:
# of stories/floors:
# of bathrooms:
( Please include any special items, such as marble or hot tubs)
Type of Foundation:
Please Select one
Slab
Crawl Space
Basement (unfinished)
Basement (finished)
Other
Type of Roof:
Select One
Asphalt/Compostion
Wood
Heavy Wood Shake
Slate
Cement Shingle
Tar and Gravel
Steel Metal
Tin
Other
Distance to Fire Hydrant:
List any dogs:
(Include type of breed)
Distance from any brush hazard:
(List distance in feet please)
Types of renovation
Year
Date Partial repair
Date Completed
Wiring
None
Plumbing
None
Heating
None
Roofing
None
Exterior Paint
None
Additional Underwriting Questions
1. Is the dwelling currently full time occupied by insured or will be within 10 days from inception of coverage? If yes please describe:
Yes
No
2. Does insured have any open claims/losses paid in excess of $5000 within the last 24 months OR losses in excess of $2,500 OR multiple(3) small claims within the last 12 months or repetitive similar cause losses?
If yes please describe:
Yes
No
3. Is dwellings owned/titled under business or with more than 2 mortgagees, or any type of business performed on premises including child care? If yes please describe:
Yes
No
4. Does insured have vicious dog(s) or dogs with bite history or farm animals where animal liability is purchased? If yes please describe:
Yes
No
5. Does dwelling have a wood burning stove that doesn't meet current building codes or stove with reclaiming heat devices or inadequately maintained? If yes please describe:
Yes
No
6. Is unit mobile homes/trailer/modular home/portable home or home witout utility services or home with pool/spa that is incompliant with built code or inproperly fenced? If yes please describe:
Yes
No
7. Is dwelling located in or near (within 1/4 mile) brush fire/landslide/forest areas or built on piers/pilings or not on solid/permanent foundation? If yes please describe:
Yes
No
8. Is dwelling under construction or extensive remodeling, renovation or with unprepared damage from previous claim? If yes please describe:
Yes
No
9. Does dwelling have copper pipes and copper wire with circuit breakers?
If yes please describe:
Yes
No
Report Claims
Please describe any claims made in the last 3 years. Check here if None
(Include dates, type, and amount paid out)
Levels of Coverages
Personal Property Coverage: $
Please list amount of coverage desired.
Liability:
*
Please Select One
$100,000
$200,000
$300,000
$500,000
Please advise me
Coverage Limit Per Occurence
Deductible:
*
Please Select one
$250.00
$500.00
$1000.00
$1500.00
$2500.00
Please advise me
Guest Medical Payments Coverage:
*
Please Select One
$1,000
$2,000
$3,000
$4,000
$5,000
Addition Comments:
Please let us know the best time to contact you?
Referred by:
IMPORTANT NOTE: This form is provided as a convenience to you. We will make a good faith effort to obtain competitive quotes for your review. Depending on the type of business, we may require more information and will contact you if necessary. Your submission of this form DOES NOT guarantee that any binding offers will be forthcoming from insurers we represent.
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