Quote Request

Welcome to our quote request form.

Empowering Your Future, Protecting What Matters.
BY USING THIS FORM YOU ARE GRANTING PERMISSION TO THE EDGAR ORTIZ AGENCY CA LIC# 4095732 TO PROVIDE A HOME INSURANCE QUOTE. ALL INDICATIONS ARE BASED ON PUBLIC INFORMATION SHOULD THERE BE ANY DISCREPANCY IT MAY CAUSE A CHANGE IN THE PREMIUM.
BY USING THIS FORM YOU ARE GRANTING PERMISSION TO THE EDGAR ORTIZ AGENCY CA LIC# 4095732 TO PROVIDE AUTO INSURANCE QUOTE. ALL INDICATIONS ARE BASED ON PUBLIC INFORMATION SHOULD THERE BE ANY DISCREPANCY IT MAY CAUSE A CHANGE IN THE PREMIUM.
Select Insurance Type*
Type of Industry*
CA LIC 4095732
Renewal Date:
Business Information
Prospect Name*
Business Name*
Name of Insured*

First NameLast Name
Owners Name*

First NameLast Name
Name of Requestor*

First NameLast Name
Name*

First NameLast Name
Insured Name*
Business Entity Type*
Sole Proprietorship, Corporation, LLC, Joint Venture, Association, etc.
FEIN*
Federal Employer Identification Number
Web Address/Social Media(if Applicable)*
Business Phone*
Owner/Executive Officers*
Driver License Number
Owners Driver License Number
Email*
Include Auto on this Policy*

YesNo
Total Annual Receipts/Sales:*
Has the current owner maintained continuous insurance coverage for the business?*

YesNo
Owners DOB:*

MonthDayYear
Date
In what year did the business start operations?*
Is this an established business with previous insurance?*

YesNo
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Owners Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Garage General Questions
Is work performed on vehicles over 20,000 pounds?*

YesNo
Number of Active Proprietors, Partners, Officers and Full Time Garage Employees*
Vehicle Kept overnight?*

YesNo
Number of Part Time Garage Employees*
Policy Details
Number of Full-time Employees: *.
Number of Part-time Employees: *.
Fire Sprinkler System:*

YesNo
Fully Sprinkler:

YesNo
Partially Sprinkler:

YesNo
Fire Sprinkler System Regularly Maintained:

YesNo
Total Annual Receipts: *.
Total Square Footage Occupied by Insured: *.
Number of Locations: *.
Total Receipts: *.
Catering Receipts: *.
Liquor Receipts: *.
What is the number of Employees: *.
Location Details
Number of Buildings: *.
Does applicant own the building?   Yes   No
Fire Sprikler System:   Yes   No*
Dry Chemical   Wet Foam   Water Spray   Other*
Are deep fat fryers used?      Yes   No*
Employee Details

(Note: If the risk has more than one location, the following table will need to be completed separately for each location.)
Does the applicant subcontract any work?*

YesNo
Does the applicant hire contract employees or pay employees with a 1099?*

YesNo
Underwriting-General Questions
Is the applicant or their employees a general contractor or hold a current general contractor license?Yes   No*
What is the total gross annual receipts for applicants business? *
Does the applicant subcontract any work?   Yes   No*
Employee Tools Coverage:   *
Prior Carrier Information

(Additional Information can be placed in Notes Section)
Carrier Name*
Enter N/A if Not Applicable
Term Year*
Enter N/A if Not Applicable
Premium*
Enter N/A if Not Applicable
Losses*

YesNo
Date of Loss

MonthDayYear
Date
Type of Loss*
Enter N/A if Not Applicable
Amount Paid*
Enter N/A if Not Applicable
Is the applicant's WC coverage currently canceled or pending cancellation?*

YesNo
Notes or Concerns
Enter all Notes or Concerns
Date of Birth (Necessary for Accurate Quote)*

MonthDayYear
Date
Insured Date of Birth (Necessary for Accurate Quote)*

MonthDayYear
Date
Phone Number*
Which life insurance?*
Height*
Weight*
How much life insurance do you want us to quote?*
Describe any health issues?
Property Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Garaging Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insured Date of Birth (Required for Accurate Quote)*

MonthDayYear
Date
Tentative Closing Date*

MonthDayYear
Date
Preferred Method of Communication*

EmailSMS/TextPhone Call
Single or Married (If Divorced or Widowed, please Mark Single.)

SingleMarried
How many other drivers need to be included on the policy? Any drivers not listed will be excluded.

No Other Drivers12345
Additional Driver 1 Name*

First NameLast Name
Additional Driver 1 DOB*

MonthDayYear
Date
Additional Driver 1 Licence Number*
Additional Driver 2 Name*

First NameLast Name
Additional Driver 2 DOB*

MonthDayYear
Date
Additional Driver 2 Licence Number*
Additional Driver 3 Name*

First NameLast Name
Additional Driver 3 DOB*

MonthDayYear
Date
Additional Driver 3 Licence Number*
Additional Driver 4 Name*

First NameLast Name
Additional Driver 4 DOB*

MonthDayYear
Date
Additional Driver 4 Licence Number*
Additional Driver 5 Name*

First NameLast Name
Additional Driver 5 DOB*

MonthDayYear
Date
Additional Driver 5 Licence Number*
How many vehicles do you need a quote?

123456Other
1st Vehicle VIN Number*
Year*
Make*
Model*
2nd Vehicle VIN Number*
Year*
Make*
Model*
3rd Vehicle VIN Number*
Year*
Make*
Model*
4th Vehicle VIN Number*
Year*
Make*
Model*
5th Vehicle VIN Number*
Year*
Make*
Model*
6th Vehicle VIN Number*
Year*
Make*
Model*
Please indicate how many*
SMS Opt-In

Under the TCPA, businesses are forbidden

from contacting consumers via SMS

without their written consent.
Check Opt-in if we have your permission to send you text messages*

Opt-In -By checking this box, you agree to receive text messages from Edgar Ortiz Agency related to your insurance needs or questions including policy reminders. You may reply STOP to opt-out at any time. Reply HELP to 661-270-3200 for assistance. Messages and data rates may apply. Message frequency will vary.Opt-Out (Do not text me!)
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Should be Empty:

Welcome to our quote request form.

CA LIC 4095732

Business Information

Garage General Questions

Policy Details

Location Details

Employee Details

Underwriting-General Questions

Prior Carrier Information

Notes or Concerns

SMS Opt-In

Under the TCPA, businesses are forbidden

from contacting consumers via SMS

without their written consent.