Earthquake Insurance Quote

Please fill out the following questionnaire as completely as possible. Remember, the more accurate the information is, the more accurate the quote will be

First Name	Last Name

Street Address

City	State	Zip

Phone	Fax	Email

What limit on Dwelling Coverage?

What limit on Contents Coverage?

What limit on Loss of Use Coverage?

What type of construction is the house?

Wood Frame Brick Masonry Veneer

In what year was the building built?

How many square feet is your house?

Do you have a fire sprinkler system?

No Yes

Please provides us with your comments here:

Theodore Insurance Agency, Inc. 20335 Ventura Blvd. #425 Woodland Hills, CA 91364

Phone: 877-4-TIA-INFO (877-484-2463)
Fax: 877-FAX-4-TIA (877-329-4842)

email: theodore insurance agency

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