Homeowners Insurance California - Current Client

What is your first name? **

What is your first name? *

What is your last name? **

What is your last name? *

What is your preferred phone number? **

What is your preferred phone number? *

Please enter your email: **

Please enter your email: *

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What is your date of birth?*

What is your date of birth?

What is your marital status? **

What is your marital status? *

What is your spouse's full name?

What is your partner's full name?

What is your fiancé's full name?

Please enter their occupation.

Please enter their employer.

Please enter their date of birth.

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Other Insured?

Will anyone else be named on this quote?

Yes
No

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Other Insured's Name

Please enter their name:

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Other Insured's Occupation & Employer

Please enter their occupation and employer name:

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Insured 2 - Date of Birth

Please enter their Date of Birth.

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Relationship Description with Other Insured

Please describe your relationship with them.

Property Information

Proposal Property Address*

Please enter the address of the location you would like an insurance proposal for. *

Street Address Address Line 2 City State ZIP Code

New Purchase?

Are you in the process of purchasing this home?

Yes
No

Purchase Price

What is the purchase price?

New Purchase Closing Date

What is the closing date?

Owned Home Effective Date

When do you need this coverage to start?

New Purchase Occupancy

Please select the intended occupancy of the property you are purchasing.

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

New Purchase Occupancy other

Please describe the intended occupancy of the home you are purchasing.

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

Please describe the occupancy of this home.

Current home address?

What is your current home address?

Street Address Address Line 2 City State ZIP Code

Primary Home Address

What is your primary home address?

Street Address Address Line 2 City State ZIP Code

New Purchase - 3 Yrs at Current Residence

Have you lived at your current address for three or more years?

Yes
No

Owned Home - 3 Yrs at Current Residence

Have you lived at your primary home address for three or more years?

Yes
No

New Purchase - Previous Home Address

Please provide the address where you lived prior to your current address?

Street Address Address Line 2 City State ZIP Code

Owned Home - Previous Home Address

Please provide the address where you lived prior to your current address?

Street Address Address Line 2 City State ZIP Code

Major Renovation

Will you do any renovations to this home after you purchase it?

Yes
No

Owned Home Major Renovation

Do you have plans to do a major renovation to this home?

Yes
No

Renovation Budget

What is the approximate budget for the renovation?

Please provide details about the renovation.

Renovation Time Frame

How long will the renovation take?

Less than 30 days
1 to 3 months
3 to 6 months
6 to 12 months
1 to 2 years

Rental Frequency

Please select the frequency of rentals for this home.

Long-Term/Annual Lease
One to Two Months per Year
Summer Rental Property/Weekly
One night to Monthly (Ie. AirBNB, Homeaway.com, etc...

New Purchase Mortgage

Will there be a mortgage?

Yes
No

What is the name of the bank providing the mortgage?

Who is your contact at the bank?

What is the phone number for your contact at the bank?

What is the email address for your contact at the bank?

Will the insurance premium be escrowed?

Yes
No
Not sure

What is the name of your current insurance company?

Is there a mortgage?

Yes
No

Please enter the bank name, if convenient.

Please enter the bank name, if convenient. (Ex. Bank of America NA, ISAOA ATIMA)

Please enter the bank address, if convenient.

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

Please enter the loan number, if convenient.

Is the insurance premium being escrowed?

Yes
No
Not sure

Trust or LLC

Is there a Trust, LLC or Limited Partnership involved in the ownership of this property?

Yes
No

Trust or LLC Name

Please enter the name of the Trust, LLC or Limited Partnership:

Alarm System

Is there an alarm system in this home?

Yes
No

Alarm System Components

Select the components of your alarm system.

Alarm

What other alarm components does your system have?

Risk Mitigation Features

Please select the risk mitigation features of this property.

Risk Mitigation Other

Enter the other risk mitigation feature(s) in this home.

Approximate Square Footage

What is the approximate square footage of this home?

Year Built

What year was this home built? (YYYY)

How many stories are there?

What is the age of your roof? (YYYY)

Please select your roof type:

Please provide a description of your roof type:

Construction Type

Please select the construction type of the home.

What is the construction type of your home?

What percentage of your home is masonry veneer?

What percentage of your home is masonry veneer? (Ex. 50%)

Which type of masonry is your home built with?

Reinforced masonry
Unreinforced masonry
Not sure

System/features Updates

Select the features of your home that have been updated.

Electrical
Plumbing
Heating
Roof
Windows
None
Other

System/features updates other

What other updates have you done to your home?

What year did you update the electrical?

What year did you update the plumbing?

What year did you update the heating?

What year did you update the roof?

What year did you update the windows?

What type of foundation does your home have?

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

Property Structures

Please select the other structures on this property.

Other Property Structures

Enter a brief description of the other structure(s) on this property.

Pool fenced?

Is the pool completely fenced in?

Yes
No

Pool diving board or slide?

Is there a diving board or slide attached to the pool?

Yes
No

Attached garage?

Is there an attached garage?

Yes
No

Attached garage car bays?

How many car bays does the attached garage have?

Additional Risks

Please select the items below that are present or will be present at this home. (Select all that apply)

Trampoline
Dog
Wood burning stove
None

Trampoline net?

Is there safety netting around the trampoline?

Yes
No

Dog breed?

What breed of dog do you have?

Valuable articles

Please select the types of valuable property you own.

Jewelry
Fine art
Other
None

Please tell us about your jewelry.

Total collection value ($)	Number of items	Value of most significant item ($)

Please tell us about your fine art.

Total collection value ($)	Number of items	Value of most significant item ($)

Please tell us about your other valuable items.

Description	Total collection value ($)	Value of most significant item ($)

Would you like a flood insurance proposal for your home?

Yes
No

Do you plan to sell an existing residence? **

Do you plan to sell an existing residence? *

Yes
No
I do not own another residence

Please enter the address of the home you plan to sell.

Street Address Address Line 2 City State ZIP Code

Wildfire and Earthquake Specific Questions

Is there a combustible deck or attached structure?

Yes
No
Not sure

Is there an exterior sprinkler system?

Yes
No
Not sure

Is this home located in a shelter-in-place community?

Yes
No
Not sure

Is this home located in a firewise community?

Yes
No
Not sure

How many feet of brush clearance surrounds the home? (Ex. 200)

Are eave soffits and attic vents fitted with narrow mesh screens?

Yes
No
Not sure

Are chimneys fitted with spark arrestors?

Yes
No
Not sure

Is firewood or other combustible materials stored at least 30 feet from the home?

Yes
No
Not sure

Are combustible structures or fuel tanks at least 30 feet from the home and have at least 10 feet around clear of combustible materials?

Yes
No
Not sure

Is the home supported by stilts, posts, cantilevers or caissons?

Yes
No
Not sure

Is the home retrofitted for earthquake? (Foundation bolts and braced crippled walls and strapped water tanks)

Yes
No
Not sure

Documents and Comments

Please use this field to upload any relevant insurance documents. (ie. Current policy declarations pages, home inspection, earthquake retrofitting certificate, etc...)

Drop files here or

Max. file size: 128 MB, Max. files: 5.

Please enter any additional remarks in the space below.

Consent*

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 *

Homeowners Insurance California - Current Client

Property Information

Wildfire and Earthquake Specific Questions

Documents and Comments

Alan Behling

RiskRevu^TM Newsletter

Contact

Homeowners Insurance California - Current Client

Property Information

Wildfire and Earthquake Specific Questions

Documents and Comments

Alan Behling

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RiskRevuTM Newsletter

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RiskRevu^TM Newsletter