CRIA Home and Building Insurance Quote Request

Home & Building Insurance Request
Today's Date

MonthDayYear
Date
How did you hear about our Agency?
Referring Realtor/Client/Vendor/Agent/etc. or OTHER Source
Name
What is your reason for shopping your insurance?

New Purchase / Ownership ChangeNon RenewalPremium / PriceCoverageLapsed due to non payment of premiumLapsed due to documentsClaims ExperienceAgency / Brokerage Customer ServiceConvenience of having everything with one AgencyOther
Other Reason:
Non Renewal Reason

Company no longer has appetite or is leaving stateHigh Fire ZoneLossesInspection report/ Maintenance ConditionsOther
Losses or Inspection Details or Other Reason
Prior/Current Insurance Carrier Name
Name
Effective Date Needed

MonthDayYear
Date
Primary Named Insured*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Occupation*
Married?*

YesNo
Spouse's Name

First NameLast Name
Spouse's Date of Birth

MonthDayYear
Date
Spouse's Occupation
Is there another Named Insured needed?

No.Yes, another individual.Yes, title will be held in the name of a Trust or LLC.Yes, title will be held in the name of a corporation or other entity.
Name of the additional Named Insured

First NameLast Name
Other Named Insured Date of Birth

MonthDayYear
Date
Other Named Insured Occupation
This additional individual will be:

On title and living in the home with PNI.On title, but not living in the home.Not on title, but living in the home with the PNI.Not on title or living in the home with PNI, but on the loan.
Additional Notes
Name of Trust or LLC
Name
Name of Corporation or Entity

Entity Legal NameDBA (if applicable)
Property Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Property Type*
Intended Occupancy within 60 days of closing escrow*

Primary Home / Owner OccupiedSecondary / Vacation Home (no rental activity)Tenant Occupied (12 month lease)Short Term Rental (Less than 12 month lease)VacantUnder Construction
Do you have or will you have any of the following in your home?

Swimming PoolTrampolineSolar PanelsProfessionally Monitored Burglar & Fire Alarm SystemAutomatic Gas Shut Off ValveAutomatic Water Shut Off Valve and whole house leak detection monitoringE Bikes or Golf Carts
Will you be doing any Home Sharing such as Air B n B or VRBO while on vacation?

YesNo
Do you own a dog(s)?

YesNo
Any of the following Dog Breeds?
Non Restricted Dog Breed Type:
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Building Usage*

OfficeRetailMedicalWarehouse/WholesaleManufacturingAutomobile ServicesRestaurantCoffee/Tea/JuiceHabitational UnitsOther
Number of Units*
The HOA Master Policy covers:

Common Liability only. It does not cover any of the Building.The Building shell. Nothing on the interior of the unit.The Building shell AND the Interior build out of the unit to original specs.The Building shell AND the Interior build out of the unit AND all upgrades.I do not know.
Does the building have any of the following recalled electrical panel types?

Federal Pacific Electric (FPE) Stab-Lok panelsZinsco / GTE Sylvania-Zinsco PanelsChallenger panels by Challenger Electric Equipment Corp or Eaton/Cutler-HammerPushmaticNo
Plumbing Type?

GlavanizedCopperPVCUnknownOther
Plumbing other
Type
Last known year Roof was completely replaced?
Year
Last known year Electrical, Plumbing, and/or A/C were completely replaced?
Year each was updated
Are there any bars on the windows?

YesNo
Do all bars have release latches?

YesJust bedroomsNo
Under Construction Type:

Complete demolition and new ground up construction.Remodel: Taken down to the studs and built back up (like new construction).Remodel: Addition of square footage and/or stories.Remodel: Interior layout re design, including movement of load bearing walls.Remodel: Interior/Exterior cosmetic only (re roof, floors, built ins, paint, etc.)
How much will be spent on the renovation/construction?*
$
Current / New Square Footage
Current / New Number of Stories
Current / New Roof Type
Current / New Garage Type
Current / New Foundation type
Any Detached Structures?

NoneADUGuest/Pool HouseStudioBack HouseSwimming PoolSignificant Hardscaping: patios, walkways, etc.Outdoor Kitchen or hardscape built ins.Other
Will your remodel include any of the following:

Foundation workEarthquake RetrofittingNeither
Additional Square Footage:
What will be built with the addition of square footage?

Additional Story(ies)Additional bedroom(s)/bathroom(s)Additional KitchenAttached ADUDetached ADUOther Separate Structures
Additional Number of Stories:
Additional Bedrooms/Bathrooms:
Describe OTHER:
Annual Anticipated Rental Income?*
$
Do you have a copy of the Association's CC&Rs? (Please obtain and forward to us)

YesNo
Additional Notes
Client's Phone Number*
Please enter a valid phone number.
Client's Email*
example@example.com
(This quote intake form was completed by:)

First NameLast Name
Should be Empty:

Home & Building Insurance Request