Personal Earthquake Insurance Quote
1
General Information
2
Current Homeowners’ Insurance Info
3
Dwelling Information
General Information
Insured 1
First Name
*
Last Name
*
Check if Legal Name is other than above
First Name
*
Last Name
*
Property Address
*
Check if mailing address is different from above
Mailing Address
*
Phone Number
*
Email Address
*
Add Another Insured
Remove Insured
1
General Information
2
Current Homeowners’ Insurance Info
3
Dwelling Information
Current Homeowners’ Insurance Info
Current Homeowners Insurance Carrier
None
Cea California Earthquake Authority
California Fair Plan
Travelers
Hartford
Farmers
State Farm
All State
Chubb Corp
CNA
Fireman’s Fund
Gaurd
AIG
CIG
Allied/Nationwide Insurance
ACE
Lloyds
Other
Please Specify Prior Carrier
Current Homeowners Insurance Policy Coverage A Limit
Current Homeowners Policy Effective Date
1
General Information
2
Current Homeowners’ Insurance Info
3
Dwelling Information
Dwelling Information
Occupied by
*
Owner
Tenant
Number of Family-Units
*
1
2
3
4
Year Built
*
Living Area (Sq.ft.)
*
Number of Levels
*
1 Story
1.5 Stories
2 Stories
3 Stories
Bi- or Split Level
Tri Level
4 Stories or More
Type of Dwelling/Single Family Dwelling
*
Residential
Renters
Townhouse
Condominium
Other
Construction Type
*
Wood Frame
Steel Frame
Masonry
Other
Please specify building type
*
Please specify construction type
*
Foundation Type
Concrete Slab
Crawlspace with a closed concrete foundation
Basement
Crawlspace with wooden perimeter
Post and piers
Stilts
Unknown
Is the foundation bolted?
*
Yes
No
Does the property have a basement?
*
Yes
No
Finished Square Footage (sq. ft.)
Unfinished Square Footage(sq. ft.)
Slope
None/Flat
Gentle than 20 Percent
Steep Greater than 20 Percent
Unknown
Minimal (1-15 degrees)
Gentle (16- 20 degrees)
Moderate (21-30 degrees)
Steep (31-45 degrees)
Very Steep (More than 45 degrees)
Roof Type:
*
Asphalt Shingle
Wood Shake or Shingle
Tar or Gravel
Manmade Concrete Shingle
Metal
Spanish Style Clay Tile
Other or Unknown
Garage Type
*
None
Attached
Built in
Carport
Detached
Basement
Size of Garage
Not Applicable
Attached
1 Car
2 Cars
more than 3 Cars
Primary Heating Source
None
Gas
Oil or Kerosene
Electric
Wood or Coal Stove
Radiant
Hot Water with Oil Furnace
Hot Water with Gas Furnace
Electric Heat Pump
Other
Central Air?
*
Yes
No
Please specify the heating source
Number of Full Baths
*
Number of Half Baths
*
1
General Information
2
Current Homeowners’ Insurance Info
3
Dwelling Information
Dwelling Information
Bath Quality (select the number of bathrooms with the following:)
How many Corian/Granite/Marble:
0
1
2
3
4
5+
Double Sink:
0
1
2
3
4
5+
Spa/Jacuzzi:
0
1
2
3
4
5+
Bath , Shower Stall:
0
1
2
3
4
5+
Kitchen Quality: (select from the following)
Corian/Granite/Marble:
*
Yes
No
Commercial Fridge:
*
Yes
No
More than 1 Oven:
*
Yes
No
6 or more range burners:
*
Yes
No
Center Island:
*
Yes
No
Additional Comments
Please give any additional information you feel appropriate for this quotation. If you have additional information where there were not enough fields above, please enter them here.
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