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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.

Property and Casualty Insurance

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 square feet?  sq. ft.

How many claims in the past 3 years?

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?

Type of foundation:  Slab    Concrete Footing    Basement    other:

Garage size:  1 car    2 cars    3 cars    other:

Is your garage:  Detached    Attached    Basement    Built-in    Car Port    No Garage

Homes Feature

Number of Bedrooms:

Number of Bathrooms:     Number of Half Baths:

Basement:  Yes    No, If yes is it:  Finished    Unfinished

Basement Square Footage:

Does the Home have a Patio?  Yes    No, if Yes what is the Square Footage:

Does the Home have a Porch?  Yes    No, if Yes what is the Square Footage:

Does the Home have a Deck?  Yes    No, if Yes what is the Square Footage:

Does the Home have any Fireplaces?  Yes    No, if Yes how many:

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 Central Air Conditioning?  Yes    No

Does the Home have a Central Vacuum?  Yes    No

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:

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