California Location Check Form

What is your first name?

What is your last name?

What is your email address?

What is your phone number?

What is the address of the home?

Street Address Address Line 2 City State ZIP Code

What type of residence is this home?

What type of residence is this home?Is the home and single family home or a condominium?

What is the replacement cost or dwelling limit of the home?

What is the additions & alterations limit of the condominium?

What is the additions & alterations limit of the cooperative?

What is your personal property coverage limit at this location?

How much jewelry coverage do you have at this location?

What is your personal umbrella limit?

Home Characteristics

Owned Home Occupancy

Please select the occupancy of this property.

Primary residence
Secondary residence
Rented to others (long-term, short-term, or seasonal tenants)
Unoccupied
Vacant (No contents remain)
Under construction/renovation
Other

Owned Home Occupancy other

What is the occupancy of this home?

What year was this home built? (YYYY)

Has this location been retrofitted for earthquakes?

Yes
No
Not sure

What year was the home retrofitted for earthquakes?

Construction Type

Please select the construction type of the home.

Wood Frame
Masonry Veneer
Reinforced Masonry
Unreinforced Masonry
Reinforced Poured in Place Concrete
Not Sure
Other

What is the construction type of your home?

What percentage of this home's construction is masonry veneer?

What percentage of this home's construction is reinforced masonry?

What percentage of this home's construction is unreinforced masonry?

How many stories does this home have?

Please select this home's roof type:

Please provide a description of your roof type:

Foundation type

What type of foundation does the home have?

Slab
Raised
Crawl Space
Perimeter with T-Footings
Caissons
On-Stilts / Piers / Posts / Cantilevered

Documents and Comments

Please use this field to upload any relevant insurance documents.

Drop files here or

Max. file size: 128 MB, Max. files: 10.

Please enter any additional remarks in the space below.

How did you hear about us?

Please share who referred you to us.

Please share what you typed into Google.

Please share how you heard about us.

<font size="2" color="gray">Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.*

Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.

Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.

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California Location Check Form

Home Characteristics

Documents and Comments

Stacey Richard

RiskRevu^TM Newsletter

Contact

California Location Check Form

Home Characteristics

Documents and Comments

Stacey Richard

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RiskRevuTM Newsletter

Contact

RiskRevu^TM Newsletter