California Earthquake Insurance Quote

Full Name:          
Address to be Insured:
City:
State:  California
Zip Code:
Email Address: (Required) 
Home Phone:   Work Phone:   Ext.
How to Contact You: Select One Phone at Work Phone at Home Email
Date of Birth:              (mm/dd/yyyy)

Do you currently have Earthquake Insurance? Select One Yes No
Coverage requested for? Select One Primary Home Second Home Condominium Apartment Townhouse Mobilehome Other
Years Lived at Address to be Insured:   Select One Less than 1 1 to 2 years 2 to 5 years Over 5 years Haven't moved in

California Earthquake Insurance Coverages & Limits of Liability:

Dwelling ($ value):
Additional Structures ($ value):
Personal Property ($ value):    

Personal Liability (each occurence): Select One $100,000 $200,000 $300,000 $500,000
Deductible: Select One 5% 10% 15%

Replacement Cost, Dwelling: Yes No
Replacement Cost, Contents: Yes No

California Earthquake Insurance - Dwelling Information:

Building Structure:    Required-Please Select Frame Wood with Stucco Mobile or Manufactured
Year Dwelling Built:     Dwelling Square Feet:   
Foundation Type:    Required-Please Select Raised Slab Pier & Post
Number of Stories:  Required-Please Select 1 1.5 2 3
Slope on hill:           Required-Please Select none less than 20% Steep Stilts/Cliff
Garage:                   Select One Attached Unattached None
Basement:               Select One Yes No
Roof Type:              Select One Composition Wood Shake Tile Spanish Tile Tar/Gravel Shingle

Is home reinforced by an earthquake resistant bracing system certified
by California Department of Housing and Community Development? Select One Yes No

Loss History:

Did you have any losses, whether or not paid by insurance, during
the last 3 years, at this dwelling location or any other location? Select One Yes No
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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