You have selected a personal Renter or Condo Insurance Quote for the state of California only.
Note: In order to provide you with an accurate quotation,
the fields marked with an asterisk ( * ) require data.
|
| |
How did you hear about Warren G. Bender Co.? |
|
| |
If you were referred by a friend, by whom were you referred?
|
|
| |
|
|
| |
Member of the following group or association: |
|
| |
| * |
Name: |
|
| |
Premises Address: |
|
| |
Apt. # |
|
| * |
City: |
|
| |
State: |
|
| * |
Zip: |
|
| * |
Phone: |
|
| |
Fax: |
|
| * |
Email: |
|
| |
|
|
| * |
Do you own the condo, apartment, or dwelling in which you live? |
|
| |
|
|
| * |
Year built (approximately)? |
|
| |
|
| |
If home is over 20 years
old, indicate any applicable updates (approximate,
if known): |
| |
Year Roof Updated: |
| |
|
|
| |
Year Wiring Updated: |
| |
|
|
| |
Year Heating Updated: |
| |
|
|
| |
Year Plumbing Updated: |
| |
|
|
| |
|
|
| * |
What amount of personal property do you need to insure? (Minimum is $20,000.) |
$
|
| |
Check all of the following functional protective devices in your residence: |
| |
smoke alarm |
dead bolt locks |
| |
fire extinguisher |
indoor sprinkler system |
| |
local burglar alarm |
centrally monitored burglar alarm |
| |
centrally monitored burglar alarm and fire alarm |
|
| |
Do you have any of the following supplemental heating devices? |
| |
fireplace |
gas fireplace |
| |
wood burning stove |
|
| |
|
|
| |
Do you have any pets on the premises(If yes, what breeds)?
|
| * |
Do you have a trampoline on the premises? |
|
| |
|
|
| |
Is the house located within 1,000 feet of a fire hydrant and 5 miles of a fire station? |
|
| |
|
|
| * |
Have you had any claims in
the last 5 years? |
|
| |
|
| |
If yes, please
explain:
|
| |
Do you need to itemize or schedule any personal property (insurance carriers limit coverage on jewelry, watches, furs, silverware, antiques, fine arts, guns and other items unless scheduled)?
If yes, please indicate the type of coverage and the amount:
|
| * |
Preferred deductible? |
|
| |
|
|
| |
Have you had a bankruptcy, repossession or foreclosure in the last 5 years? |
|
| |
|
|
| |
Do you want earthquake coverage on this home? |
|
| |
|
|
| |
Would you also like to receive a flood quote on this home? |
|
| |
If yes, how much contents coverage would you like to include? |
|
| |
|
|
| |
Does your home have a basement? |
|
| |
|
|
| |
Is the bank requiring this insurance for your loan? |
|
| |
|
|
| |
Have you had any flood losses at your residence? |
|
| |
|
| |
Additional Comments:
|
* |
How would you like to receive your quote?
|
|
| |
|
|
| |
|
|
