(626) 584-6303
Pasadena, CA
Stephen B. Groton, California Insurance
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Your Information
Property Owner's Name
*
Property Owner's Residence Address
Email
*
Phone Number
*
Date of Birth
Occupation
Property Location
Address
City
State
Zip Code
*
County
Current Insurance Information
Company Name
Current Annual Premium
Expiration Date
Coverage 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
Is this a short-term, vacation or seasonal rental?
Yes
No
Earthquake Coverage Desired?
Yes
No
Do you occupy this dwelling at anytime during the year?
Yes
No
If Any Dogs, What Breeds or Mixes and How Many?
Dwelling Information
Is this home tenant-occupied with a lease?
Yes
No
Estimated Replacement Cost
Square Footage
Year Constructed
If Home is over 20 Years Old, What
HVAC and Electrical
Updates Have Been Made?
Age of Hot Water Heater?
Roof
Type
(comp shingle, tile, metal) and
Age
?
Are water pipes all copper, galvanized iron, PEX or mixed?
How Many Floors?
1 Story
1.5 Story
2 Story
Bi-Level
Tri-Level
Other
Type of Construction
Wood Frame
Stucco Exterior
Solid Masonry
Brick Veneer
Aluminum Siding
Clapboard Exterior
Other
Other Home Features
(check all that apply)
Dead Bolts
Smoke Detectors
Fire Extinguisher
Located within 5 miles of Fire Station
Located 1000 feet from Fire Hydrant
Swimming Pool
Trampoline
Home Located within City Limits
Claims
List any claims in past 3 years:
Date of Claim
Amount Paid
Claim Type
Description
1.
2.
3.
Personal Property
Estimated value of your personal property on premises (appliances, etc.):
Do you own any other rental properties?
Yes
No
How many?
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