Address to be Insured:
Email Address: (Required)
Home Phone: Work Phone: Ext.
How to Contact You:
Date of Birth: (mm/dd/yyyy)
Do you currently have Earthquake Insurance?
Coverage requested for?
Years Lived at Address to be Insured:
California Earthquake Insurance Coverages & Limits of Liability:
Dwelling ($ value):
Additional Structures ($ value):
Personal Property ($ value):
Personal Liability (each occurence):
Replacement Cost, Dwelling: Yes No
Replacement Cost, Contents: Yes No
California Earthquake Insurance - Dwelling Information:
Year Dwelling Built: Dwelling Square Feet:
Number of Stories:
Slope on hill:
Is home reinforced by an earthquake resistant bracing system certified
by California Department of Housing and Community Development?
Did you have any losses, whether or not paid by insurance, during
the last 3 years, at this dwelling location or any other location?
If the answer to the previous question was "Yes", please explain below.
Date Type Description of Loss Loss Amount
Additional Information or Comments
Click on the "Submit Quote Information" button below to
send your California Earthquake Insurance quote request.**
**Information received from this California Earthquake Insurance quote request
form sent to "YOUR AGENCY NAME" will be for our use only and will
not be sold given to or distributed to any other parties. A quote will be based
on the earthquake insurance policy information provided and does not guarantee
acceptance of the risk by us. The precise coverage afforded is subject to
meeting underwriting guidelines, and the terms, conditions and exclusions of
the policy as issued. By submitting this request you acknowledge that this is
neither an offer to insure nor a guarantee of insurance. Completion of this
form does not entitle you to a California Earthquake Insurance Policy. We
are licensed in California and will not provide quotes for other states.
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