(626) 584-6303
Pasadena, CA
Stephen B. Groton, Insurance Broker
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Policy Holder
Contact Name
*
Email
*
Phone Number
*
Date of Birth*
Property Location
Address (include apartment or unit number)
City
State
Zip Code
*
Current Insurance Information
Company Name
Current Annual Premium
Expiration Date
Insurance Information
Deductible Desired
$100
$250
$500
$1000
$1500
$2000
$2500
$5000
Amount of Liability Desired or Required by Landlord
$100,000
$500,000
$300,000
$200,000
$1,000,000
Earthquake Coverage Desired?
Yes
No
If Any Dogs, How Many and What Breed?
Contents Information (your stuff)
Is this a house or an apartment?
House
Apartment
Estimated Replacement Cost of your Personal Property (contents)
Security Features
(check all that apply)
Dead Bolts
Smoke Detectors
Fire Extinguisher
Central Station Fire Alarm
* = Required Field
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