In a Rush, Complete this questionnaire and call us at 408-286-1111.


 
 

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408-286-1111 ext 106
408-997-7890
CA Lic#
0697055
 
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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
Name of Insured:
Address:

     
(street)        

(City)


(zip)
 
   
Contact Person:
(First)

(Last)
Telephone:
Fax:
Cell Phone:
Email Address:
Qualification Questions
Any Brush Location with less than 150ft clearance? :
Yes No
Any claims in the past five years? :
Yes No
Any coverage cancelled or denied in the past three years? :
Yes No
Primary Location Details
Address of Primary Location:

     
(street)        

(City)


(zip)
 
   
Year Built:  
If schedule equipment is over $100,000, advide name of central statation alaram company at primary address:
Location in a Brush Area?:
Yes No
Has location been retrofitted?:
Yes No
Prior Coverage
Carrier Name:
Policy Number:
Expiration Date:  
Coverage Options
Coverage Start Date:  
Coverage End Date:  
Category Limit to Insure
Jewelry (In Bank Vault):
Jewelry (Out of Bank Vault):
Fine Arts (non-Fragile):
Fine Arts (Fragile):
Furs:
Cameras, Projection machines, films, etc :
Sporting Event:
Music Instruments:
Silverware:
Postage Stamps:
Rare Coins & Collections:
Computers & Media:
Wine:
Golf Carts:
Bicycles:
Guns/Firearms:
Miscellaneous Collections:
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California Lic # 0697055
1494 Hamilton Ave #101, San Jose, CA 95125