Earthquake Insurance
* = Required Information
This is not an instant quote website; our prices are too low to list online. Please fill out the quote form to obtain a Earthquake insurance quote, and an insurance specialist will contact you shortly. Please understand this is not an application for insurance. An application will be sent to you if coverage is desired.
Earthquake Fact Finding Questions
Of the following, what is your primary purpose for an earthquake policy? Investment Protection 
Requesting More INFO 
Loan Required 
Of the following, what is most important to you? Price 
Proper Coverage 
Approximately when was the last time you did a review with your agent? Within the year 
Over 2 years ago 
Over 5 years ago 
Please rate the following in the order that you feel are most important
for you to protect?
In the event of an untimely death, is it important to you that you're surviving spouse and/or children maintain the quality of life you currently have together without debt? Yes 
Contact Information
First Name
Last Name
Gender Male     Female 
Date of Birth
Marital Status
Home Address
Zip Code
The Best Time to Call?
Best Phone Number to Reach You
Email Address *
Home Information
Policy Renewal Date
Home Types
Residence Types
Current Dwelling Replacement Cost:
Square Feet
Construction Type
Roof Type
Year Built:
Number of Stories
Number of Bedrooms
Number of Bathrooms
Garage Types
Central Air Conditioning: Yes     No 
Has the brush been cleared by 250 feet from all sides of the building? Yes     No 
Utilities Type
Home Options:
Fenced Pool
 Yes    No   Yes   No 
Security Options:
Smoke Detectors
Dead Bolt Locks
 Yes    No   Yes   No 
Fire Extinguisher
Automatic Fire Sprinklers
 Yes    No   Yes   No 
Alarm System:    
Home Owners Association? Yes     No 
Homeowners Policy Information
When Do You Need This Policy To Start?
How long have you lived at your present address?
Current Insurance Company?
Current Annual Insurance Premium?
Is your policy being Canceled or Non-Renewed?
(We can help!)
Yes     No 
If you are being canceled or have any reported claims
in the last Five years, briefly explain why: (reason/date/description/amount paid/claim opened
or closed)?
Desired Deductible?
Liability Amount?
Medical Payments
Do you need jewelry coverage? Yes     No 
Do you need Mortgage Protection Insurance? Yes     No 
To receive a larger discount would you consider also
insuring your cars?
Yes     No 
Do you need a Home Warranty Quote? Yes     No 
Do you need a Flood Insurance Quote? Yes     No 
Do You Need an Umbrella Policy?
Contact Me During:
Earthquake Policy Information
Dwelling Coverage Amount:
What is the earthquake deductible?
Loss Of Use Amount Requested:
Current Insurance Company?
What is the Current Annual Premium?
Additional Information