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Contact Information
Name
Address
City, State, Zip Code
Telephone
Cell Phone
Fax
Email
Best time to call
Please send quote via
Email
Fax
Mail
Call Me
How did you hear about us?
Select:
WaMu Bank
AAGLA - Apartment Assoc of Greater Los Angeles
Other Apartment Association
Yellow Pages Ad
Search Engine
Other
Occupation
How long at current job?
years
months
Add property location if different from above
CURRENT INSURANCE COMPANY
Company Name
Policy Expiration Date
Present Insured Value of Home
Liability Limit Desired
Select:
300,000
500,000
1,000,000
Other
HOME INFORMATION
How long at your present address?
Years
Months
# of Claims in last 3 years
Sq. footage of home (excluding garage and basement)
Year home was built
STRUCTURE INFORMATION
Type
Select:
1 Story
1.5 Story
2 Story
Split-Level
Bi-Level
Other
Construction
Select:
Frame or Stucco
Masonry or Veneer
Masonry
Other
Roof
Select:
Asphalt Shingle
Wood Shingle
Tile or Slate
Other
Age of Roof in years:
yrs
Foundation
Select:
Basement
Crawlspace
Slab
Other
Garage
Select:
1
2
3
4
None
Type of Garage:
Select:
Attached
Detached
Basement
Built-In
Carport
None
FEATURES
Bathrooms
# of Full
# of Half
Basement
Select:
None
Finished
Unfinished
Square Ft
Deck/Porch/Patio
Deck Sq Ft
Porch Sq Ft
Screened Patio Sq Ft
Fireplaces
# of Chimneys
# of Hearths
ADDITIONAL FEATURES
Heating System
Select:
Electric
Gas
Oil
Propane
Solar
Other
Central Air
Yes
No
Central Vac
Yes
No
Security Alarm
Select:
None
Monitored
Not Montored
Fire Alarm
Select:
None
Monitored
Not Montored
Smoke Detector
Yes
No
ADDITIONAL COMMENTS:
* Please note coverage will not be written nor bound prior to confirmation from Fuller Insurance Agency. The information you provide is sent to our office and an agent will contact you directly with a quote.
