Earthquake Insurance Form

What is your first name? **

What is your first name? *

What is your last name? **

What is your last name? *

What is your email address? **

What is your email address? *

What is your phone number? **

What is your phone number? *

What is the address of the property you would like an earthquake insurance proposal for? **

What is the address of the property you would like an earthquake insurance proposal for? *

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is the above address the same as the mailing address?

Yes
No

What is your mailing address?

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What is the name of your current home / Dwelling / Building insurance company?

What is the dwelling limit on your current home / dwelling / building policy?

Do you have earthquake coverage currently?

Yes
No

What is the name of the insurance company your current policy is with?

What is the dwelling limit for earthquake coverage on your current earthquake policy?

What is the personal property limit for earthquake coverage on your current earthquake policy?

What date would you like this earthquake coverage to go into effect? **

What date would you like this earthquake coverage to go into effect? *

What is the number of families that can occupy this home?

How many floors/stories does this home have? (Count the basement as a story, if there is one)

What is the construction type?

What is the foundation type?

Please provide a description of your foundation.

What type of exterior siding does your home have?

Please enter the exterior siding type.

What percentage of the dwelling's exterior does the masonry veneer cover?*

What percentage of the dwelling's exterior does the masonry veneer cover?

What is the roof type?

Please enter your roof type.

What was the year built of this home / dwelling / building?

Has this home had prior earthquake damage?

Yes
No

How many times has the home / dwelling / building been damaged by earthquake?

What was the date of this loss?

Please tell us about the prior damage from this loss?

Has the prior earthquake damage been repaired?

Yes
No

What was the total cost of the repairs from this loss?

What was the date of the second loss?

Please tell us about the damage from the second loss?

Has the earthquake damage from the second loss been repaired?

Yes
No

What was the total cost of the repairs from the second loss?

What was the date of the third loss?

Please tell us about the prior damage from the third loss?

Has the prior earthquake damage from the third loss been repaired?

Yes
No

What was the total cost of the repairs from the third loss?

Is this home on the historical registry?

Yes
No

Is the home, in whole or in part, extended over a cliff or a steep hill?

Yes
No

Is the home, in whole or in part, extended over water?

Yes
No

Are there any additional insureds? (I.e. Banks, Trusts, LLCs, etc.)

Yes
No

Please enter the requested information for each additional insured.

Additional Insured Name	Address	Loan # (if Applicable)

Earthquake Retrofitting

Is the dwelling bolted or anchored securely to the foundation?

Yes
No

What is the distance between the bolts or anchors?

What date was the bolting or anchoring work completed?

Was the work done to the entire dwelling?

Yes
No

What area of the dwelling was the bolting or anchoring done to?

Does the dwelling have cripple walls?

Yes
No

Are the cripple walls braced with plywood?

Yes
No

Has 100% of the perimeter been braced?

Yes
No

Please explain why 100% of the perimeter has not been braced.

What type of water heater does the dwelling have?

Conventional Storage Water Heater
Tankless (On-Demand) Water Heater
Heat Pump Water Heater
Solar Water Heater
Condensing Water Heater
Combination Boiler

Is the water heater strapped to prevent movement?

Yes
No

Does the dwelling have an automatic seismic shutoff valve?

Yes
No

Please upload your earthquake retrofitting certificate, if available.

Max. file size: 128 MB.

What dwelling coverage limit do you want for this earthquake coverage?

What coverage limit do you want for other structures?

What coverage limit do you want for personal property?

What coverage limit do you want for loss of use or alternative living expense coverage?

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.

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Please share how you heard about us.

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. *

I agree*

Earthquake Insurance Form

Earthquake Retrofitting

Documents and Comments

Spencer M Houldin

RiskRevu^TM Newsletter

Contact

Earthquake Insurance Form

Earthquake Retrofitting

Documents and Comments

Spencer M Houldin

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RiskRevuTM Newsletter

Contact

RiskRevu^TM Newsletter