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California Insurance QUOTE
LIFE INSURANCE
LIFE INSURANCE
• Life Insurance Quotes
Question
Dwelling Fire Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!
Your Personal Data
Your Name
Property Address to be insured
City
State: (Must be California)
Zip Postal
E-Mail (REQUIRED)
E-Mail (again for accuracy)
Phone
Fax (optional)
Dwelling Information
Year Home Built
Home Square footage:
Is this Builder's Risk? (new home constr.)
NO      YES
Month/Year home to be complete
Number of units
1 family      Duplex
3 family      4 family
Occupancy
Owner Occupied
Tenant Occupied
Type foundation
Basement
Slab
Crawlspace over slab
Other (list in remarks)
(If basement, what % is finished?) % FINISHED
Type Construction
Frame
Brick/Veneer
Stone
Other
Type Roof
Shingle
Wood Shake
Tar/Gravel
Spanish Tile
Metal      Other
Number of stories
One
1.5
Two
Three
Do you own animals or pets?
If yes, list type/for dogs, list breed:
Yes      No
Are You Near Brush Area?
Yes      No
# of feet to nearest fire hydrant
# of miles to nearest fire station
Does Home Have a Garage?
Tell whether built in, detached/attached, and how many cars?
Yes      No
Currently Insured?
Name of Carrier & how long insured?
Yes      No
Prior Claims?
Describe claims in detail
Yes      No
Rate Your Credit History and Past Insurance Payment History
(Some companies products are based on your credit and payment history.)
Excellent      Fair
Poor      Horrible
Plumbing type
Copper      Galvanized
Mixed (Copper/Galvanized)
Circuit Breakers or fuses?
Breakers      Fuses
# Bedrooms     
# Bathrooms     
# Fireplaces     
# Chimneys     
Special features
(i.e., deck, air conditioning, alarm systems, pool, etc.)
Coverages
Dwelling Cov. $
Contents $
Liability Cov. $
Deductible $
($250, $500, $1,000, etc.)
Comments/Remarks
(describe any scheduled jewelry, in-home business, or other special coverages needed here)
Send my quotation via:
E-Mail                  Fax
Regular Mail      Call Me By Phone
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Simons Insurance Agency
CA License #0772640
12743 Bellflower Blvd. Downey, CA 90242
Toll Free: 800-646-2366
Local Phone: 562-803-9501
Fax: 888-346-2245
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