1. TYPE OF COVERAGE:

FIRE    HOMEOWNERS    RENTERS

2. CLIENT INFORMATION:


NAME:  

MAILING ADDRESS:

CITY:  STATE: CA   ZIP CODE:

PHONE:  EMAIL ADDRESS:

3. LOCATION INFORMATION:

ADDRESS:      CITY:

STATE: CA    ZIP CODE:

INTEREST: Owner Tenant  CONSTRUCTION TYPE: Frame Masonry Metal  #STORIES: 1 2 3 4 5 6 7 +

YEAR BUILT:   TOTAL AREA: Sq.Ft.

NUMBER OF UNITS: SINGLE DUPLEX TRIPLEX FOURPLEX   GARAGE ATTACHED DETACHED   SIZE 1 2 3 4

4. BURGLAR ALARM:  NO  YES   "IF YES"   LOCAL CENTRAL

FIRE PROTECTION:   NO  YES   EXTINGUISHERS: HOW MANY 1 2 3 4

SPRINKLERS: FULLY  PARTIAL

5. UPDATE INFORMATION:

ELECTRICAL UPDATE:    TYPE: FUSES CIRCUIT BRAKERS    

ROOF UPDATE:    TYPE: SHINGLES WOOD SHAKES ROCK TILE    

PLUMBING UPDATE:    TYPE: COOPER GALVANIZED

HEATING UPDATE:    TYPE: CENTRAL HEATING WALL HEATER

6. DESIRED COVERAGES:

CONTENTS $

7. LIABILITY LIMITS: $ $ 500,000 $ 300,000 $ 100,000

COMMENTS: