(760) 770-2827 Rancho Mirage, CA

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Contact Name *

Email *

Phone Number *

Date of Birth*

Occupation

Property Location

Address

City

State

Zip Code *

County

How did you find our agency?*

Social Media

Customer Referral

Google Search

Google Ad

Current Insurance Information

Company Name

Current Annual Premium

Expiration Date

Insurance Information

Deductible Desired

Amount of Liability Desired

Earthquake Coverage Desired?
Yes No

Windstorm Coverage Desired? (not applicable in all states)
Yes No

If Any Pets, What Breed?

Dwelling Information

Is this home owner occupied or a rental?
Owner Occupied Rental

Estimated Replacement Cost

Square Footage

Year Constructed

Is Your Home over 20 Years Old? If so, What Updates Have Been Made?

Age of Hot Water Heater?

Roof Type and Age?

How Many Floors?
1 Story
1.5 Story
2 Story
Bi-Level
Tri-Level
Other

Type of Construction
Wood
Stucco
Masonry
Brick Veneer
Aluminum Siding
Other

Other Home Features (check all that apply)

Dead Bolts

Smoke Detectors

Fire Extinguisher

Central Station Fire Alarm

Central Station Burglar Alarm

Located within 5 miles of Fire Station

Located 1000 feet from Fire Hydrant

Swimming Pool

Trampoline

Home Located within City Limits

Claims List any claims in past 3 years:

Date of Claim

Amount Paid

Claim Type

Description

Date of Claim

Amount Paid

Claim Type

Description

Date of Claim

Amount Paid

Claim Type

Description

Personal Property Estimated value of your personal property:

Jewelry & Watches

Furs

Silver

Firearms

Stamp and Coin Collections

Fine Arts and Breakable Items

Note: Coverage Can Not Be Bound Changed Or Deleted Via Electronic Message

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Insurance Super Store | 72877 Dinah Shore Dr, Suite 103 | Rancho Mirage, CA 92270 | (760) 770-2827

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