Agent Info:
Name : Steven Longenecker
License ID : Various
Phone : (303) 808-9351
Email : [email protected]
Address : 2362 Eagleview Circle, Longmont, Colorado, 80504

Earthquake Insurance

  • Applicant
  • Property Address
  • Property
  • Carrier
  • Coverage
  • Finish

Applicant

Can you tell us about yourself?

First Name *
Last Name *
Date of Birth *
Marital Status

Where should we send your quote?

Email *
Phone *

Please fill all the mandatory questions.

Property Address

Property Address

Address *
City *
State *
Zip Code *

Billing Address

Address *
City *
state *
Zip Code *

Please fill all the mandatory questions.

Property

Construction of the Dwelling

Construction Class *
Parking Class *
Year Built
Number of Stories
Building Shape
Setbacks or Overhangs?

History

Year Wiring/​Electrical was Renovated *
Year Plumbing was Renovated *
Year Heating was Renovated *
Year Roofing was Renovated *
Year Exterior Paint was Renovated *

Occupancy

Occupancy *
Explain Occupancy Class in Detail
Insured's Interest

Please fill all the mandatory questions.

Carrier

Please tell us about your current insurance

Prior Insurance
Prior Insurance Carrier
Prior Insurance Expiration Date

Loss/Claims 1

Please tell us about your current insurance

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

Please fill all the mandatory questions.

Coverage

Requested Coverage

Requested Effective Date
Building Limit *

(100% Replacement Cost Required)

Business Personal Property

(100% Replacement Cost Required If Applicable)

Loss of Use
Deductible Option *
Ordinance or Law *

Business Income/Extra Expense

(Provided on a per location basis)

BI/EE 1

BI/​EE

Additional Property Coverage

(Provided on a per location basis)

APC 1

APC
Which APC's are application for this location

Please fill all the mandatory questions.



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