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A Service of Simons
Insurance Agency
12743 Bellflower Blvd.
Downey, CA 90242
Toll Free: 800-646-2366
Local Phone: 562-803-3101
Fax: 888-346-2245
satisfaction
Homeowners Insurance Quotation Form
One Simple Form - takes only 2-3 Minutes!
Your Personal Data
Your Name
Property Address
City
Your "County" is?
State: (Must be California)
Zip Code
E-Mail (REQUIRED)
E-Mail again for accuracy
Phone
Fax (optional)
Primary Policyholder's Birthdate:
(REQUIRED - Some companies products
offer discounts for certain age groups.)
Dwelling Information
Year Home Built:
Home Square footage:
Is this Builder's Risk?
(new home constr.)
NO      YES
Month/Year home
o be complete:
Number of units:
1 family      Duplex
Type foundation:
Basement
Slab
Crawlspace over slab
Other (list in remarks)
(If basement, what % is finished?) % FINISHED
Type Construction:
Frame
Brick/Veneer
Stone
Other (list in remarks)
Type Roof:
Shingle
Wood Shake
Tar/Gravel
Spanish Tile
Metal      Other
Number of stories:
One      1.5
Two      Three
Do you own animals or pets?
Yes      No
Are You Near Brush Area?
Yes      No
# of feet to nearest
fire hydrant:
# of miles to nearest
fire station:
Does Home Have a Garage?
Yes      No
Tell whether built in, detached/attached, and how many cars?
Currently Insured?
Yes      No
Name of Carrier & how long insured?
Prior Claims?
Yes      No
Describe claims in detail
Rate Your Credit History and Past Insurance Payment History: (Some companies products are
based on your credit and payment history.)
Excellent      Fair
Poor      Horrible
Plumbing type:
Copper      Galvanized
Mixed (Copper/Galvanized)
Heating Type:
Gas (Propane or natural)
Electric
Oil (if oil, list tank location in remarks)
Circuit Breakers or fuses?
Breakers      Fuses
# Bedrooms
# Bathrooms
# Fireplaces
# Chimneys
Special features
(i.e., deck, air conditioning, alarm systems, pool, etc.)
Coverages
Dwelling Cov. $
Contents $
Liability Cov. $
Deductible $
($250, $500, $1,000, etc.)
Comments/Remarks
(describe any scheduled jewelry, in-home business, oil tank location, or other special coverages/remarks here)
Send my quotation via:
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Simons Insurance Agency
CA License #0772640
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