All items are required in order to provide an accurate proposal.
Full Name
Name of Agency/Brokerage
Address
City
State
ZIP
Phone
Fax
E-Mail
Represent
Name of Buyer's Agent
Buyer's Agent Phone
Buyer's Agent Fax
 

Salutation
Full Name
Current Mailing Address
City
State
ZIP
Home Phone
Work Phone
Fax
E-Mail
Alternate Phone
   
 

Type Of Transaction
Address
City
State
ZIP
Property Will Be Occupied By
Type Of Property
Year Built
Square Footage
Floor Plan
Foundation Type
Roof Material
Roof Condition
Fire Sprinklers
Type of Alarm System
Garage
Garage Type
Any Losses In The Past 5 Years?
If Yes, Date(s) Of Loss
Description of Losses
Amount of Paid Losses
Is a paid fire station located within 5 miles: and a fire hydrant within 1,000 feet of the house?
Is the home within 400 feet of any native brush or forest area?
Is the home on well water or city water?
Will the home be occupied within 30 days after closing escrow?
Will there be any animals on the property?
If Yes, what type(s)
Is there a swimming pool present?
If Yes, is there a slide or diving board?
   
 

Company Name
Escrow Officer
Escrow #
Phone
Fax
E-Mail
Projected Closing Date
Comments or Questions

   
 
 
 
 

This form is a request for an insurance proposal and is not an insurance policy contract or an actual offer of insurance for the subject property. Insurance will not be in effect until the insurance company approves the application, and that acceptance is subject to the usual and customary underwriting standards of the company.

CA License #0E16973