Homeowners insurance quote request form

Mikkelsen Insurance Services

Information needed to give indication of Homeowners Insurance premium. Please complete all fields, enter "None" or "N/A" if not applicable. (Read our Privacy Statement). Quotes are available in the following California Counties Only: Alameda, Contra Costa, San Joaquin and Stanislaus.

Name:
Address:
City:	, California
Zip Code:
Home Phone:
Work Phone:
E-mail Address:
Current Carrier:
Expiration Date:

Property Information: (Owner occupied or rental? )
Address if different:
California City & Zip Code:
Insured Value: - Year Built: - Square Feet:
Const. Type? Frame/stucco, Brick etc.:
Number of Stories? - Fireplace? - Type of Heating/Air?
Roof Type: - Garage:
Smoke Detector?Y/N	Fire/Burglar Alarm Type?

Any Dogs? Yes/No:	Type of Dogs?
Swimming Pool?	If Yes, is it enclosed by 6' fence?

In City Limits?

Distance to Fire Sta.:

Distance to Hydrant:

If house is over 25 years of age, we need information on updates, please give details:

Plumbing? What year?

Electrical? What year?

Roof? What year?

Any claims in the last five years? (Please give complete details, type, date, amount etc.)

Deductible?

Liability Limit?

Additional information:

Before you press "Send", please double check form for completeness and accuracy. We can not respond to your request if there is missing information. If you prefer, print and fax to: 209-839-8632