1. TYPE OF COVERAGE:

   FIRE HOMEOWNERS RENTERS

2) CLIENT INFORMATION:

   NAME  

   MAILING ADDRESS  

   CITY , STATE CA.  ZIP CODE

   PHONE # EMAIL ADDRESS

3) LOCATION INFORMATION:

   ADDRESS:

   CITY:STATE: CA  ZIP:

   OCCUPIED BY: Owner Tenant CONSTRUCTION TYPE: Frame Masonry Metal WOODSIDING #STORIES: 1 2 3

   YEAR BUILT: TOTAL AREA:Sq.Ft.

   NUMBER OF UNITS: SINGLE DUPLEX TRIPLEX FOURPLEX GARAGE: ATTACHED DETACHED SIZE: 1 2 3 4

4) BURGLAR ALARM: NO YES "IF YES" LOCAL CENTRAL

   FIRE PROTECTION: NO YES  EXTINGUISHERS: HOW MANY 1 2 3 4

   SPRINKLERS: FULLYPARTIAL

5) UPDATE INFORMATION: 

   ELECTRICAL- UPDATED:  TYPE: FUSES CIRCUIT BREAKERS

   ROOF- UPDATED  TYPE: SHINGLES WOOD SHAKES ROCK TILE

   PLUMBING- UPDATED: TYPE: COPPER GALVANIZED

   HEATING- UPDATED:  TYPE: CENTRAL HEATING WALL HEATER

6) DESIRED COVERAGES:

   CONTENTS $

7) LIABILITY LIMITS:$ $   500,000 $   300,000 $   100,000

COMMENTS