(626) 584-6303
Pasadena, CA
Stephen B. Groton, California Insurance
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Policy Holder
Contact Name
*
Email
*
Phone Number
*
Date of Birth*
Property Location
Address
City
State
Zip Code
*
Current Insurance Information
Company Name
Expiration Date
Insurance Information
Deductible Desired
$100
$250
$500
$1000
$1500
$2000
$2500
$5000
Amount of Liability Desired
$100,000
$500,000
$300,000
$200,000
$1,000,000
Earthquake Coverage Desired?
Yes
No
If Any Dogs, How Many and What Breed?
How Much Loss Assessment Coverage
$1,000
$5,000
$10,000
$25,000
Dwelling Information
Is this home owner occupied or rented to a tenant?
Owner Occupied
Rental
Dwelling / structure value; additions and alterations, walls, etc. (coverage A on your current policy)
Square Footage
Year Constructed
How Many Floors?
1 Story
1.5 Story
2 Story
Security Features
(check all that apply)
Dead Bolt Locks on all Exterior Doors
Smoke Detectors
Fire Extinguisher
Central Station Fire Alarm
Central Station Burglar Alarm
Claims
List any claims in past 3 years:
Date of Claim
Amount Paid
Claim Type
Description
Personal Property
Estimated
replacement
value of your personal possessions, contents, "your stuff":
* = Required Field
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