Call us on (916) 251-3548
HOMEOWNERS INFORMATION SHEET
Insured's name (required) Date
Street address Referred by
City ZIP New Purchase?
Phone home: Escrow Close?
Phone work: Current Carrier
No. Stories ---123 Policy # Expiration
DWelling coverage amount
Year built Occupancy owner tenant vac liability
Substructure: ---crawl spaceslabbsment
Type of construction: Deductible
Exterior walls Earthquake
SQ. FT Roof type Dogs Breed Bite
Garage Attached? Detached? Pool? SPA? Fenced?
AUTO QUOTE SHEET
There are a few questions I need to ask you
If single, live alone or have rmmate? or live w/parents?
Your DOB Spouse DOB Other DOB Other DOB
Type of vehicle
Year Make Model Bodystyle
No. Cylinders #1 VIN #
#2 VIN #
Is use of vehicle work? or pleasure? #1 #2 #3 #4
Miles to work one way? #1 #2 #3 #4
Annual mileage: #1 #2 #3 #4
Have you received a moving violation in the past 5 years? (yes/no)
Have you been involved in an accident as a driver in the past 5 years? (yes/no)
If yes, when? What type?
Have you ever had a major violation? (yes/no)
ZIP code How long licensed in US? How long licenced in CA?
Do you have insurance at the present time? (yes/no)
If no, have you had any in the last 10 days? (yes/no) Yes, with whom?
Was it continous for one year? (yes/no)
What limits are you carrying now? Liability? Prop damage
How high of a deductible are you willing to go? Comp Coll
Do you want uninsured motorist? (yes/no) Do you want alt U/M? (yes/no)
Your name (required) Telephone where I can call you back (required)
Day: Time: Work:
Your Email (required)