Quote Online Or Print Application Home Obama care CIGNA Domestic CIGNA International CIGNA Global Plans Sign In Contact Us info@insure123.com 408-286-1111 408-997-7890 CA Lic# 0697055 Or Book a meeting With Mr. Zain   News CEO Zain Jeewanjee Interview on WomenNow TV Quote Request for Homeowners Insurance Please answer all questions to prevent a delay in processing your quote request. If you have any questions call us at 408.286.1111 for help or fax at 408.997.7890 Contact Information Contact Person: (First) (Last) Date of Birth: / / mm / dd / yyyy SSN: Property Address: (Apt) (City) ---Select a state--- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming (zip)       Telephone: Cell Phone: Home Phone: Fax: Email Address: Best Time to Contact: Morning Afternoon Evening Send Quotes via: Select an Option Phone E-Mail Fax Additional Information Are you currently insured? Yes No Type of Property: Select One Single Family Town House Comdominium Duplex Fourplex Sixplex Apt.Complex Vacant Land Occupancy (check all that apply): Owner Occupied Rented to Others Second Home/ Vacation Rental Number of Claims on any property owned in the last 36 months? None 1 2 3 4 5 or more Specific Information on the Home Construction of Home: Select One Wood Frame Brick/Masonry Concrete Style of Home: Select One Ranch Cape Split Level Colonial Raised Ranch Contemporary Row House (attached on either side) Town House Number of Stories: Select -> 1 1.5 2 2.5 3 3.5 4 or more (excluding basement) What year was the home built?: What type of Foundation supports the home?: Not Sure Concrete Slab Crawl Space Basement (finished) Basement (unfinished) Pilings Roofing Material: Asphalt or Architectural Shingles Clay or Spanish Tile Slate Wood Shake Concrete Tiles Don't know Type of Heating: Select One Oil Gas Electric Steam Oil or Gas Burner replaced or updated recently: Yes No How many amps in electrical service: Select One 120 220 Don't know Garage Type: Select One None Attached Built-in(rooms above) Detached Number of cars garage holds: None 1 2 3 4 or more Security Features (check all that apply): Smoke Detectors Fire Extinguishers Dead Bolts Local Burglar Alarm (rings outside home) Local Fire Alarm (rings outside home) Central Station Burglar Alarm Central Station Fire Alarm (Central station means connected directly to a monitoring facility that contacts police or fire dept on your behalf) Home Features Central Air: No Yes Number of Bathrooms: 1 1.5 2 2.5 3 3.5 4 5 5.5 6 # Fireplaces: None 1 2 3 4 Swimming Pool: None Above Ground In-Ground Insurance Coverage What is the purchase price of the home? $ Mortgage Amount $ Dwelling Amount help $ Personal Property Cov. $ Personal Liability Cov.help $ $100,000 $200,000 $300,000 $500,000 $1,000,000 Deductible:help $100 $500 $1000 $1500 $2500 Is Earthquake Coverage Required? Yes No Do you need coverage for scheduled personal property (jewels, furs, silver) beyond what the standard policy offers? Usually big ticket items. help: Yes No If yes, give amt in $'s for each example $12,000 Jewelry $ Furs     $ Silver   $ Other   $ Underwriting Questions Underwriting questions (as you may know, credit has become a major factor in obtaining insurance in a number of states, so please be aware that where applicable, rates will be quoted based on your responses below) Filed For Bankruptcy in last 5 years?: Yes No Is Your Credit Rating: Good Excellent Fair Poor Do you have a pet? Yes No Other types of insurance you would like to see: Auto Business Auto Flood Boat/Yacht Do you Smoke? Yes No Comments: Are you a robot?

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