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On-Line Earthquake
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!


Your Personal Data:

Your Name:
Property Address:
City:
State: (Must be California)
Zip/Postal:
E-Mail (REQUIRED):
E-Mail (again to verify):
Phone (Optional):
Fax (Optional):
Year Home Built:
Home Square footage:
Current H/O Carrier:
Current H/O Cov. Amt. $
 
Is Home Retrofit by
Licensed Contractor?
Yes No
 
Quake coverage now?
(Required Field)
Yes No
 
Current Quake Carrier (type none if no coverage):
(Required Field)
 
Number of units: 1 family Duplex
3 Family 4 Family
 
Occupancy: Owner Occupied Rental
 
Type Construction: Wood Frame Wood w/stucco
Brick (NOT ELIGIBLE!)
 
Type foundation: Slab Pier & Post
Crawlspace over slab
Other (list in remarks)
 
Type Roof: Shingle Wood Shake
Tar/Gravel Spanish Tile
 
Number of stories: One 1.5
Two Three
 
Slope (On hill?): None Gentle (>20 degr.)
Steep Stilts/cliff
 
Comments/Remarks:
 
Send my quotation via: E-Mail Fax
Regular Mail
Call Me by Phone


Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release them from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me an Earthquake Quote!

 
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