In order to receive preliminary insurance and initial quote information please fill and send in the following form. Thank you!
NAME
PREMISE ADDRESS (including ZIP code)
YEAR DWELLING BUILT
UPDATES FOR WIRING. PLUMBING, ROOF AND HEATING if over 35 years old.
NUMBER OF STORIES / TOTAL SQUARE FOOTAGE
ROOF TYPE Tile Wood Shake Tar and Gravel Fiberglass / Asphalt Shingles Other
ALARMS/SECURITY SMOKE FIRE BURGLAR SPRINKLERS
OTHER SWIMMING POOL
LOSS HISTORY (last 5 years)
DWELLING COVERAGE AMOUNT AND DEDUCTIBLE $500 $1000 Other if other, please specify
VALUE OF PERSONAL CONTENTS COVERAGE AMOUNT (TENANTS)
ADDITIONAL COVERAGES REPLACEMENT COSTS EARTHQUAKE JEWELRY FINE ARTS SILVER OTHER:
PERSONAL LIABILITY LIMIT $100,000 $300,000 $500,000
General Comments / Additional Questions
How did you first discover or learn about us? WWW Magazine Newspaper Friend Other
Please contact me by:
Email
Phone If you'd like to be contacted by phone, please indicate the best time for us to call. BETWEEN Please select a time range 7AM - 12PM 12PM - 5PM 5PM - 8PM
Fax
Mail Address
Thank you for your time! - Plaza Insurance Sales, Inc.
