Name
Phone







6650 Reseda Blvd
Suite #108
Reseda, CA 91335

contact@gisinsure.com
Earthquake Insurance
First Name:
Last Name:
Business Name:
Mailing Address:
Mailing City:
Mailing State:
Mailing Zip Code:
Phone Number:
Fax Number:
Property Information
 

Property Address:

 

Property City:
Property State:
Property Zip Code:
Occupancy Type:  
Building Type:  
Year Built:
How Many Stories:
Total Square Footage of the Building:  
How Many Units Are In The Building:
Garage Description:  
Construction Type:  
Foundation Type:  
Nature of Sub-Soil:  
Topography:  
Roof Type:  
Roof Updated: yes no
If Yes, Year Roof Updated:
Any Erosion in the Area? yes no  
Any Below Ground Parking? yes no  
Any Soft First Story or Tuck Under Parking? yes no  
Protection Distance:
Is the Building in the Brush Area? yes no  
Is there a Brush Hazard within (1) mile of the Building? yes no  
If yes, has the Brush been cleared by 250 feet from all sides of the Building? yes no  
Smoke Detectors: yes no  
Fire Extinguishers: yes no  
Electrical Updated:
Circuit Breakers: yes no
Heating - Air Conditioning, How Old?
Plumbing Updated: yes no
If Yes, Year Plumbing Updated:
Copper Plumbing: yes no  
Automatic Sprinklers: 
Fire Alarm:
Earthquake Retrofitted or Bolted: 
Current Insurance Company:
Losses-Claims in the last 5 years:   
If Yes, Date, Amount Paid and Description of each Loss-Claim 

 

Coverage Information
 

Building Coverage:

 

Other Structures Coverage:
Contents Property Coverage:
Loss of Use Coverage:
Earthquake Deductible: