RENTERS WORKSHEET

First Name: Last Name: Phone Number: Fax Number: E-Mail Address:    PROPERTY INFORMATION   Property Address:   Property City: Property State: California Property Zip Code: Year Built: Date You Moved In: How Many Units In The Building: How Many Stories Is The Building: Total Square Footage of Your Dwelling:   Construction Type: Frame Masonry Veneer Masonry Superior   Roof Type: Tile Slate Metal Woodshake Composite Material   Roof Updated: yes no  If Yes, Year Roof was Updated: Protection Distance: 1000 ft or less to a hydrant & 5 mi or less to a fire station Over 1000 ft to a hydrant & 5 mi or less to a fire station Over 5 & up to 10 mi to a fire station Over 10 mi to a fire station  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? yesno  Smoke Alarm: yesno Fire Extinguisher: yesno  Deadbolts: yesno Electrical Updated: Yes, Recently Updated No  Circuit Breakers: yes no Copper Wiring: yes no Heating - Air Conditioning, How Old?: Heating - Air Conditioning, Thermostatically Controlled?: yesno  Energy Source:  Gas Electrical  Heating - Air Conditioning, Central? yes no  Plumbing Updated: yesno If Yes, Year Plumbing was Updated: Copper Plumbing: yes no  Interior Automatic Fire Sprinklers:  None Partial Full  Theft Alarm: None Local Central  Fire Alarm: None Local  Fire District: Current Insurance Company: Any Dogs on the Property: yes no If Yes, Number & the Breed of Each Dog:   Any Other Pets-Animals on the Property: yes no  If Yes, Number & Description of Each Pet-Animal: Losses-Claims in the last 5 years:  None One Two Three Four Five   If Yes, Date, Amount Paid & Description of Each Loss-Claim    COVERAGE INFORMATION   Personal Property (Coverage C):   Loss of Use (Coverage D): Premise Liability (Coverage E): >$300,000 $100,000 $500,000 > Policy Deductible: >100 250 500 750 1000 2500 5000 > Contents Replacement Cost Coverage: yesno Please press the Submit Button ONCE. Then wait for online confirmation of your request. Thank you for your interest.