Home Insurance Application

Phone: (800) 455-8191 Fax: (951) 280-9979

Please fill out the information below:

Please enter your first and last name:

Date of birth:

Marital Status:

Email

Address:

Phone number:

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Policy Information

Policy Type: Primary Residence Rental Vacation

Is the home under construction? Yes No

Is there a business on the premises? Yes No

Is there a swimming pool on the premises? Yes No

Are there dogs on the premises? Yes No

Are horses and/or livestock kept on the premises? Yes No

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Dwelling Information

Year Originally Built:

Construction Style: 1 Story 2 Story 3 Story

Dwelling Type: Single Family Residence Duplex Triplex Fourplex

Total Living Area:

Roof Material: Tile - Clay/Concrete Comp. Shingle Wood Shake

Heating: Gas/Propane - Forced Air Space Heater Wood Stove

Exterior Walls: Stucco Wood Concrete

Foundation Type: Slab Crawl space Basement

Total # of Baths
Full 1 2 3 3/4 1 2 3 1/2 1 2 3

Fire Sprinklers System: Yes No

Burglar Alarm Type: Central Station Alarm Local Alarm No Alarm

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Garages and Carports: 1 Car Attached 2 Car Attached 3 Car Attached 4 Car Attached 1 Car Detached 2 Car Detached 3 Car Detached 4 Car Detached

Attached Structures: Porch - Open Wood Deck Patio

Number of Fireplaces: 1 2 3 4 5

Air Conditioning: Central A/C Mounted Units

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Deductibles and Property Coverages

All Perils Deductible: $250 $500 $1000 $2500

Coverage E - Personal Liability: $100,000 $300,000 $500,000

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Optional Coverage

G - Unscheduled Jewelry: $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 $9,000 $10,000