Untitled Document

CGA Associates Earthquake Insurance Application Form
For the fastest and most accurate insurance quote, please provide as much information possible in the form below. This information will be kept confidential and will be used for quote purposes only!

Submitting Information

Business Name:
Contact Name:
Street Address:
City:	State: ZIP:
County:	Email:
Business Phone:	Fax:

Applicant Information Section
First Name:
Last Name:
Phone Number:
Fax Number:
E-Mail Address:

Property Information Section
Property Address:
Property City:
Property State:
Property Zip Code:
Dwelling Type:
Numbers Of Bedrooms:
Number Of Bathrooms:
Number of Fireplaces:
Garage Description:
Year Built:
Date You Purchased Your Home:
How Many Stories:
If Two Stories, Ground Floor Square Footage:
Total Square Footage of Your Dwelling:
Does The Dwelling Have A Basement?	yes no
Construction Type:
Roof Type:
Roof Updated:	yes no
If Yes, Year Roof was Updated:
Property Topography:
Foundation Type:
Protection Distance:
Is Dwelling in the Brush?	yes no
Is there a Brush Hazard within (1) mile of Your Dwelling:	yes no
If yes, has the Brush been cleared by 250 feet from all sides of Your Dwelling?	yes no
Smoke Alarm:	yes no
Fire Extinguisher:	yes no
Electrical Updated:
Circuit Breakers:	yes no
Copper Wiring:	yes no
Heating - Air Conditioning, How Old?:
Heating - Air Conditioning, Thermostatically Controlled?:	yes no
Energy Source:
Heating - Air Conditioning, Central?	yes no
Plumbing Updated:	yes no
If Yes, Year Plumbing was Updated:
Copper Plumbing:	yes no
Interior Automatic Fire Sprinklers:
Fire Alarm:
Fire District:
Current Insurance Company:
Expiration Date of Current Insurance Policy:
Losses-Claims in the last 5 years:
If Yes, Date, Amount Paid & Description of Each Loss-Claim

Coverage Section
Dwelling Amount (Coverage A):
Other Structures (Coverage B): Usually 10 % of Coverage "A"
Personal Property (Coverage C): Usually 50 % of Coverage "A"
Loss of Use (Coverage D):
Policy Deductible:

Additional Comments

Please give any additional comments about the coverage you desire: