Personal Lines Earthquake EZ-APP

Applicant Information

Name Type: Applicant Name: Applicant Home Number: Applicant Work Number: Applicant E-Mail Address: Location Address: Policy Effecitve Date:

Property Information:

Year Built: Total Square Feet: Construction Type: Number of Floors (including basement): Structure Type: Coverage A Replacement Cost Value: Coverage B Other Structures: Coverage C Personal Property: Coverage D Loss of Use: What is the Dwelling Foundation Type: Does the foundation meet seismic retrofitting requirements?: Is the home considered to be historical or is the home located in a historical district? Is the home built over water? Is there excessive mold or wood rot which affects the structural integrity? Is the building undergoing construction or renovation? Is there any unrepaired structural or earthquake damage to the insured location?

Personal Lines Earthquake EZ-APP

Applicant Information

Property Information:

Agency Information