HOMEOWNERS QUESTIONNAIRE

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Bolds Insurance Brokerage

1447 Fourth Street

San Rafael, CA  94901

Phone: (415) 485-1700  Fax: (415) 485-1866

License #0D35007

 

NAME/ADDRESS

First Name

 Last Name

Street

City/State/Zip

          -     

 

CONTACT INFORMATION

Phone Work

Phone Home

Email Address

Your Occupation

LOCATION INFORMATION   same as mailing address (skip below)

Street Address
City/State/Zip
          -     

 

Dwelling Limit: (replacement cost)* do not incl land value
Deductible:
Personal Liability Limit:
Year Built* Fire Extinguishers yes  no
Year Purchased Dead Bolt Locks yes  no
Number of Stories Fire Sprinklers yes  no
*if over 25 years old, quote will be subject to updated plumbing, electrical & roof Central Station Alarm yes  no

LIST ALL CLAIMS WHICH HAVE OCCURRED DURING THE PAST 5 YEARS

if none, check this box and skip the next section

Date of Claim

Amount of Claim

Brief Description

include any additional claims in the comment section of this form
COMMENTS