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Earthquake Insurance

* = Required Information

This is not an instant quote website; our prices are too low to list online. Please fill out the quote form to obtain a Earthquake insurance quote, and an insurance specialist will contact you shortly. Please understand this is not an application for insurance. An application will be sent to you if coverage is desired.

Earthquake Fact Finding Questions

Of the following, what is your primary purpose for an earthquake policy?	Investment Protection Requesting More INFO Loan Required

Of the following, what is most important to you?	Price Service Proper Coverage

Approximately when was the last time you did a review with your agent?	Within the year Over 2 years ago Over 5 years ago Never

Please rate the following in the order that you feel are most important for you to protect?	Income: Auto: Savings: Home: Other:

In the event of an untimely death, is it important to you that you're surviving spouse and/or children maintain the quality of life you currently have together without debt?	Yes No

Contact Information

First Name

Last Name

Gender

Male Female

Date of Birth

Marital Status

Occupation

Home Address

Zip Code

The Best Time to Call?

Best Phone Number to Reach You

Fax

Email Address *

Home Information

Policy Renewal Date

Home Types

Residence Types

Current Dwelling Replacement Cost:

Square Feet

Construction Type

Roof Type

Year Built:

Number of Stories

Number of Bedrooms

Number of Bathrooms

Fireplace

Garage Types

Central Air Conditioning:

Yes No

Has the brush been cleared by 250 feet from all sides of the building?

Yes No

Utilities Type

Home Options:

Pool	Fenced Pool
Yes No	Yes No

Security Options:

Smoke Detectors	Dead Bolt Locks
Yes No	Yes No

Fire Extinguisher	Automatic Fire Sprinklers
Yes No	Yes No
Alarm System:

Home Owners Association?

Yes No

Homeowners Policy Information

When Do You Need This Policy To Start?
How long have you lived at your present address?

Current Insurance Company?

Current Annual Insurance Premium?

Is your policy being Canceled or Non-Renewed? (We can help!)	Yes No

If you are being canceled or have any reported claims in the last Five years, briefly explain why: (reason/date/description/amount paid/claim opened or closed)?

Desired Deductible?

Liability Amount?

Medical Payments

Do you need jewelry coverage?	Yes No

Do you need Mortgage Protection Insurance?	Yes No

To receive a larger discount would you consider also insuring your cars?	Yes No

Do you need a Home Warranty Quote?	Yes No

Do you need a Flood Insurance Quote?	Yes No

Do You Need an Umbrella Policy?

Contact Me During:

Earthquake Policy Information

Dwelling Coverage Amount:

What is the earthquake deductible?

Loss Of Use Amount Requested:

Current Insurance Company?

What is the Current Annual Premium?

Additional Information