6400 Laurel Canyon Blvd. Suite 305
North Hollywood, CA 91606
Phone. 818.789.0722
Fax. 818.789.2835
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Homeowners, Condo & Renters Insurance Quote
Owners Name:
Property Address:
Property Address 2:
City, State Zip:
,
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Email Address:
Contact Phone Number:
Dwelling info
Check all that apply
Owner Occupied
Vacant
In Construction
For Sale
Vesting
Husband and Wife as Joint Tenants
A Single Man
A Single Woman
As His Sole and Separate Property
As Her Sole and Separate Property
As Tenants in Common
As to an Undivided 1/2 Interest
As Community Property
An Unmarried Man
An Unmarried Woman
As Joint Tenants
Coverage Type
Home
Condo
Renters
Deductible
500
1,000
2,500
5,000
Dwelling Value
Personal Liability
100,000
300,000
500,000
1,000,000
2,000,000
Medical
1,000
2,500
Personal Property
Mo/Yr Purchased
Sq. Ft.
Num. of Stories
Construction Type
Frame
Masonry
Concrete
Steel
Other
Year Built
Num. of Rooms
Foundation Type
Slab
Raised
Other
Deadbolts
Yes
No
Smoke Detectors
Yes
No
Fire Sprinklers
Yes
No
Brush Area
Yes
No
Garage Spaces
0
1
2
3
3+
Pool
Yes
No
Fenced
Yes
No
Diving Board
Yes
No
Gated Community
Yes
No
Dog
Yes
No
Fireplace(s)
0
1
2
3
4
5
6
6+
Building Improvements
Fully
Updated
Partially
Updated
Year
Improved
Type
Heating
Gas
Electric
Electrical
>
Circuit Breakers
Fuses
Roofing
>
Metal
Wood Shake
Tar & Gravel
Composite
Other
Plumbing
Copper
Galvanized
PVC
Does the Building have a central Alarm? Yes
No
If yes, who installed it and can you provide a certificate?
Additional Information
Mortgagee Info:
Name 1
Address 1
Name 2
Address 2
Loan Number
City, State Zip
,
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Please list any additional info below.
ie. More than one mortgagee, claims made in the last 5 years, high value items.
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