| Producer Name: * |
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| Producer Code: * |
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| Producer Fax: * |
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| Producer Email: * |
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Please indicate which way to send your quote
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Fax quote
Email quote |
| Named Insured: * |
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| 2nd Named Insured: |
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| Address: * |
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| City, State * |
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| Zip Code: * |
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| Insured Phone Number: * |
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| Mailing Address, if applicable: |
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| Please select the carriers to quote |
Geovera
Pacific Select
AXIS Reinsurance
Universal North America |
Please choose the desired deductible options
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15% Standard
10% Comprehensive
15% Comprehensive |
For Axis quotes only
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AXIS Pool Endorsement (up to $25,000) |
| Does the risk have existing EQ Damage?: * |
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| Is the risk under course of construction?: * |
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| Prior Earthquake Carrier: * |
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| Year Built: * |
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| Living Area: * |
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| Number of Levels: * |
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| Foundation Type: * |
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| Foundation Bolted (Y/N)?: * |
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| Does the dwelling have Cripple Walls? (Y/N): * |
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| If Basement, please indicate sqft area.: |
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| Daylight Basement (Y/N)?: |
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| Is dwelling withing 500ft from the beach (high tide line)? (Y/N): * |
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| Unit Type: * |
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| Number of Units: * |
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| Construction Type: * |
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| Slope (within 50ft of dwelling): * |
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| Garage Type: * |
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| Garage Size: * |
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| Roof Material: * |
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| Primary Heat Source: * |
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| Central Air Conditioning: * |
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| Number of Full Bath: * |
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| Number of Half Bath: |
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Select the number of bathrooms that have the following items:
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| Corian, Granite, Authentic Marble Countertops: |
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| Spa or Jaccuzi Tub: * |
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| Double Sink: * |
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| Bathtub and seperate shower stall: * |
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Kitchen Quality (choose all that apply):
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Corian, Granite, Authentic Marble Counter top
Commercial Style Refrigerator
More than one oven
6 or more total range top burners
Center island w/ cabinets or sink |
| Please select up to six (6) siding types. Indicate the percentage of each type of material by entering a value of 0-100 for each item (or leave blank if 0%). |
| Adobe: |
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| Aluminum: |
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| Brick Solid |
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| Brick Veneer or Brick on Frame: |
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| Log Siding: |
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| Stucco on Frame: |
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| Stucco on Block: |
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| Stone Veneer: |
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| Stone (Solid): |
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| Vinyl: |
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| Wood Shake: |
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| Wood Siding/Plank: |
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| Flooring Type and Percentage (optional): |
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| Wall Covering type and Percentage (Optional): |
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| Number of Masonary Chimney: * |
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| Number of Wooden Chimney: * |
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| Describe any decks or porches (include sqft): |
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| Swimming Pool Characteristics: * |
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Please check if applicable
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Central Fire Alarm
Burglar Alarm |
| Shape of Building: |
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| Current Fire Ins. Carrier (For Axis quotes): |
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| Coverage A (for Axis quotes): |
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| Coverage C (Contents for Axis Condo quotes): |
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| Remarks: |
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I am interested in the EQ Deductible Buyback Program and a quote for my client! |
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