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California Insurance QUOTE
LIFE INSURANCE
LIFE INSURANCE
• Life Insurance Quotes
Question
Homeowners Insurance Quotation Form
One Simple Form - takes only 2-3 Minutes!
Your Personal Data
Your Name
Property Address
City
Your "County" is?
State: (Must be California)
Zip Code
E-Mail (REQUIRED)
E-Mail again for accuracy
Phone
Fax (optional)
Primary Policyholder's Birthdate:
(REQUIRED - Some companies products
offer discounts for certain age groups.)
Dwelling Information
Year Home Built:
Home Square footage:
Is this Builder's Risk?
(new home constr.)
NO      YES
Month/Year home
o be complete:
Number of units:
1 family      Duplex
Type foundation:
Basement
Slab
Crawlspace over slab
Other (list in remarks)
(If basement, what % is finished?) % FINISHED
Type Construction:
Frame
Brick/Veneer
Stone
Other (list in remarks)
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?
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?
Yes      No
Tell whether built in, detached/attached, and how many cars?
Currently Insured?
Yes      No
Name of Carrier & how long insured?
Prior Claims?
Yes      No
Describe claims in detail
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)
Heating Type:
Gas (Propane or natural)
Electric
Oil (if oil, list tank location in remarks)
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, oil tank location, or other special coverages/remarks here)
Send my quotation via:
E-Mail                  Fax
Regular Mail      Call Me By Phone
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We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.
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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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