Name
Phone







6650 Reseda Blvd
Suite #108
Reseda, CA 91335

contact@gisinsure.com
RENTERS CONTENTS INSURANCE
First Name:
Last Name:
Phone Number:
Fax Number:
E-Mail Address:
Who Referred You To Our Site?

PROPERTY INFORMATION
 

Property Address:

 

Property City:
Property State:
Property Zip Code:
Year Built:
Date You Moved In:
How Many Units In The Building:
How Many Stories Is The Building:
Total Square Footage of Your Dwelling:  
Construction Type:  
Roof Type:  
Roof Updated: yes no  
If Yes, Year Roof was Updated:
Protection Distance:
Is Dwelling in the Brush? yes  no  
Is there a Brush Hazard within (1) mile of Your Dwelling: yes no  
If yes, has the Brush been cleared by 250 feet from all sides of Your Dwelling? yes no  
Smoke Alarm: yes no
Fire Extinguisher: yes no  
Deadbolts: yes no
Electrical Updated:
Circuit Breakers: yes no
Copper Wiring: yes no
Heating - Air Conditioning, How Old?:
Heating - Air Conditioning, Thermostatically Controlled?: yes no 
Energy Source: 
Heating - Air Conditioning, Central? yes no 
Plumbing Updated: yes no
If Yes, Year Plumbing was Updated:
Copper Plumbing: yes no  
Interior Automatic Fire Sprinklers: 
Theft Alarm:
Fire Alarm:
Fire District:
Current Insurance Company:
Any Dogs on the Property: yes no
If Yes, Number & the Breed of Each Dog:  
Any Other Pets-Animals on the Property: yes no  
If Yes, Number & Description of Each Pet-Animal:
Losses-Claims in the last 5 years:   
If Yes, Date, Amount Paid & Description of Each Loss-Claim 

 

COVERAGE INFORMATION
 

Personal Property (Coverage C):

 

Loss of Use (Coverage D):
Premise Liability (Coverage E):
Policy Deductible:
Contents Replacement Cost Coverage: yes no