Phone:
1.888.867.2050
Fax:
1.888.867.2050
Address:
6014 Reseda Blvd.
Tarzana, Ca 91356
Email:
araxins@yahoo.com
HOMEOWNERS INSURANCE QUOTE
Personal Information
Name:
Address:
City:
State:
Zip:
Day Phone:
Night Phone:
Best Time To Call:
AM
PM
Email Address:
Occupation:
How Long At Current Job:
Current Homeowners Insurance Information
Company Name
(not agency)
:
Policy Expiration Date:
Premium Amount: $
Amount Insured For:
$
Policy Type:
Primary
Secondary
Term:
6 Months
1 Year
Other:
Current Homeowners Insurance Information
Company Name
(not agency)
:
Policy Expiration Date:
Premium Amount: $
Amount Insured For:
$
Policy Type:
Primary
Secondary
Term:
6 Months
1 Year
Other:
Home Information
How Long At Present Address:
Year Home Was Built:
Sq. Footage (excluding garage
and basement):
sq. ft. # of Claims In Last 3 Years:
Structure Information
Type
Construction
Roof
Foundation
Garage
1 Story
1 1/2 Story
2 Story
Split Level
Bi-Level
Other
Frame
Stucco
Veneer
Masonry
Other
Asphalt Shingle
Wood Shingle
Tile or Slate
Other
Basement
Crawl Space
Slab
Other
1 Car
2 Car
3 Car
4 Car
None
Age of roof:
yrs.
Attached
Detached
Basement
Built-in
Car Port
None
Features
Bathrooms
Basement
Deck/Porch/Patio
Fireplaces
# of Full:
# of Half:
None
Finished
Unfinished
Sq. Ft.:
Deck Sq. Ft.:
Porch Sq. Ft.:
Screened Patio Sq. Ft.:
# of Chimneys:
# of Hearths:
Additional Features
Heating System
Central Air
Central Vac
Security Alarm
Fire Alarm
Smoke Detector
None
Electric
Gas
Oil
Propane
Solar
Other
Yes
Yes
None
Monitored
Not Monitored
None
Monitored
Not Monitored
Yes
Scheduled Personal Property
Please indicate additional property that is not listed in boxes 10-14
#
Property
Amount of Ins.
#
Property
Amount of Ins.
1
Jewelry
$
8
Coins
$
2
Furs
$
9
Golfer's Equipment
$
3
Fine Arts
$
10
$
4
Cameras
$
11
$
5
Musical Instruments
$
12
$
6
Silverware
$
13
$
7
Stamps
$
14
$
Unattended Car Coverage (Stamps/Coins)
Broad Form Pair & Set Coverage
Non-Mobile Organ Coverage
Safe Credit (Identify Property, Safe Class, Etc)
ACV Loss Settlement
Replacement Cost Loss Settlement
Breakage Coverage (*On Schedule)
Blanket Coverage
Additional Rating Information
Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.
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