Please fill out the following questionnaire
as completely as possible. Remember, the more accurate the information
is, the more accurate the quote will be
Date
Referred
By:
Current Carrier(if any):
Expiration
Date:
Owners Name/Legal Entitiy:
Property
Address:
Mailing Address:
Email:
Phone:
Fax:
Square Footage:
# Bedrooms:
# Bathrooms:
Building
Construction:
Roof Construction:
Year Built:
Exterior Fountains: No Yes
Description:
Exterior Railings: No Yes
Description:
Dwelling Limit: (if known)
Contents Limit:
Theft w/Violence:
Glass Limit:
Fine Arts / Jewelry: (Need current appraisals) Coverage
Applies only ON PREMISES
Money & Securities:
Earthquake:
Palapa:
General Liability: $1,000,000 (Standard) Lower Limits
Available ($100,000, $300,000, $500,000)
