Curtis Moring Insurance Agency, Inc. Think CMI for all your insurance needs.

Insurance Coverage

 
California Homeowner's (Older Home) Quote
Homeowner's Application
(Application for dwellings over 25 years old)
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Name of Insured:
Property Address:
City:
State: Zip Code:
 

Tel. No:
Fax No:
Email Address:
Broker Name:
Contact:
Code of Producer:
If more space is needed, please fill out a blank sheet & attach to back
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nRoof
Type:
  
Composition Metal Slate
Tar & Gravel Tile Wood
Date roof was last replaced:
By Whom:
Please reference program for age restrictions and endorsements
nPlumbing
Has all the plumbing been upgraded?
If no, see program for surcharge
Yes
No
Month & Year Updated:
Is the water heater properly strapped?
Yes
No
Explain extent of work completed:  
nElectrical
Has dwelling been updated to copper wiring on circuit breakers?
If no, risk is prohibited
Yes
No
 
Month & Year Updated:
Was work completed by qualified electrician?
Yes
No
 
If no, by whom?
nContractor/Engineer/Inspector
Name:
Professional Title:
Business License No:
 Bonded with State:
Yes
No
Business/Organization Name:
Business Address:
City:
State: Zip Code:
 
Tel. No:
Fax No:
Email Address:
 
Signature of Contractor:
Date:
  
I have reviewed the above information and it is true and complete to the best of my knowledge.
Applicant Signature:
I have reviewed the above information and it is true and complete to the best of my knowledge.
Agent/Broker Signature:
 
Curtis Moring
Insurance Agency, Inc.
 
 
License #0719355
 
 
(800) 321-0677
 
p: (619) 718-7575
 
f: (619) 718-7565
  email:
 
 
This form is not an insurance policy or an insurance contract. Your agreement to these terms does not create an insurance contract or agreement. These terms must be accepted by the insurance company before there is any contract or coverage.
 
Serving California consumers since 1963. PRIVACY POLICY.
© Copyright 2008 Curtis Moring Insurance Agency, Inc. 123 Camino De La Reina, Suite 202 East, San Diego,
California 92108. Site design by SFDesign '03. All rights reserved.