BMP Insurance Services

Homeowners Insurance Quote

Homeowner's insurance can help protect your house and the personal items in your home. Basic coverage California homeowner's insurance can prepare you for an unexpected loss or damage. In addition, homeowner's insurance can give you a valuable safety net for your California investment.

APPLICANT INFORMATION
First Name:
Last Name:
Home Phone:
Work Phone:
E-Mail Address:
Referred By:

PRIOR INSURANCE
Prior Homeowners Insurance:

If "Other," Enter Insurer Name:

Time With Insurer:
Estimated Yearly Premium:
Policy Ends On:

PROPERTY INFORMATION
Property Address:
City:
State:
ZIP Code:
Property Surroundings:
Distance to Fire Station:

Distance to Hydrant:	Under 1,000 feet Over 1,000 feet
Year Built:
Property Use:
Square Footage:
Number of Families:
Number of Stories:
Construction Type:
Roofing Material:
Age of Roof:
Electrical Type:
Heat Type:
Number of Bathrooms:
Number of Fireplaces:
Dog Type:
Burglar Alarm:
Fire Alarm:
Smoke Detectors:

Fire Extinguishers: (on each floor)	Yes No Not Sure
Fire Sprinkler System:
Number of Basements:
Est. Basement Sq Ft:
% Basement Finished:
Garage Type:
Est. Garage Sq Ft:
Swimming Pool:
Swiming Pool Fence Construction Type:

PROPERTY VALUE
Purchase Date:
Purchase Price:
Est. Current Market Value:
Est. Replacement Value:

ADDITIONAL INFORMATION

Any reported losses during the past 3 years?		Yes No

Any business conducted on premises? (including day/child care)		Yes No

Any residence employees?		Yes No

Has applicant had a foreclosure, repossession or bankruptcy during the past five years?		Yes No

Does applicant own any recreational vehicles (snowmobiles, dune buggies, mini bikes, ATVs, etc.)?		Yes No

Is building retrofitted for earthquake?		Yes No Not Sure

COVERAGE LIMITS AND DEDUCTIBLES

Dwelling

Other Structures

Personal Property

Loss of Use

Personal Liability

Medical Payments

All Perils Deductible

Non-Smoking Household?	Yes (nonsmokers) No (smokers)

Comments: