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ARG & Associates will provide you with a free, no-obligation Home and Earthquake Insurance quote. The information below is kept confidential. Please answer as many questions as possible, so we can provide you with the most accurate quote.

Home and Earthquake

Personal Information

Name:                        Date:

Address:

City:

State:

Zip:

Phone:                      Best time to call:   am    pm

E-mail:

Insurance Information

Currently Insured with:

Policy Number:            Policy Expiration Date:

Premium Amount: $       Insured Amount: $

Term of Insurance:  6 months    1 year    other:

Homes Information

How long have you had this address?

Year home was built:

How many claims in the past 3 years?

How many units in are in the building?

Homes Structure

Number of Story:  Single Story     1 &1/2 Story    2 Story    Split Level    Bi Level    other:

Structure:  Frame    Stucco    Veneer    Masonry    other:

Roof:  Asphalt Shingle    Wood Shingle    Tile or Slate    other:

How old is the roof?

Homes Feature

Number of Bedrooms:

Number of Bathrooms:     Number of Half Baths:

Does the Home have Central Heating  Yes    No      What Type of Heater does the Home have?  Natural Gas    Propane    Electric    Oil    Wood    Solar    Other:

Does the Home have a Security System?  Yes    No, if Yes, is it  Monitored   Not Monitored

Does the Home have a Fire Alarm?  Yes    No, if Yes, is it  Monitored   Not Monitored

Does the Home have a Smoke Detector?  Yes    No

Additional Details

Please list below any additional details in the space provided below:

When you click "Submit Quote" button, your application will be emailed to one of our representatives, who will contact you shortly.

      

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