Agent Info:
Name : Denis Mehulic
License ID : 0L58079
Phone : (408) 674-3569
Email : [email protected]
Address : ste 201 1095, San Jose, California, 95136

Fire

  • Applicant
  • Home
  • Property
  • Carrier
  • Coverage
  • Finish

Applicant

Can you tell us about yourself?

First Name *
Last Name *
Birthdate
Marital Status

Where should we send your quote?

Email *
Phone *

What is your Occupation or education degree

(discounts may apply)

Educational Degree
Occupation

Please fill all the mandatory questions.

Home

Home Address

Address *
City *
State *
Zip Code *

Billing Address

Address *
City *
State *
Zip Code *

Please fill all the mandatory questions.

Property

Construction of the Home

Occupancy Type *
Type of Construction *
How many square feet is your dwelling *
What is your type of roof?
Year of construction?
How is the quality of your home
Percentage of the house that is complete?
Pet Details
Type of Pet

Protection

How close are you to the brush area?

Construction of the Home

Specify Pet
Breed of Pet

Protection

History

Year Wiring/​Electrical was Renovated *
Percentage Wiring/​Electrical was Renovated
Year Plumbing was Renovated *
Percentage Plumbing was Renovated
Year Heating was Renovated *
Percentage Heating was Renovated
Year Roofing was Renovated *
Percentage Roof Renovated

Please fill all the mandatory questions.

Carrier

Please tell us about your current insurance

Home Insurance
Current Home Insurance Carrier
When does your policy expires? *
Are you being cancelled or non-renewed? *

Losses / Claims 1

Loss / Claim details
Type of loss *
Date of loss
Amount of Loss
Description of loss

Please fill all the mandatory questions.

Coverage

What are your coverage limits?

Current dwelling value *
What is your Liability Limit

Additionals

What do you do?

Additionals

Please fill all the mandatory questions.



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