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General Information
Name:*	Street:*	City:*	State:*

Zip Code:*	Email:*	Phone:	Date of Birth
Occupation:	How Long at Current Job:

Current Homeowners Insurance
Company Name:	Policy Expiration Date:	Amount Insured For:
Premium Amount:	Policy Type:

Home Information
Yrs at Present Address:	Year Home Was Built:	Sq. Footage:	# Claims in Last 3 Yrs

Structure Information

Type:	Roof:	Age of Roof:
Garage:	Type of Garage:	Construction:
Features
# of Full Bathrooms:	# of Half Bathrooms:	Basement:	Basement Sq. Ft:

Deck Sq. Ft.:	Porch Sq. Ft.:	Screened Patio Sq. Ft.:	# of Chimneys:


Additional Features
Heating System:	Central Air: Yes	Smoke Detector: Yes
Central Vac: Yes	Security Alarm:

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Landlord/Tenant

McKenzie Smith Eagle West Insurance Services, LLC 1341 N. McDowell Blvd., Ste. A, Petaluma, CA 94954
Phone (707) 778-9200 Toll Free (800) 300-9149 Fax (707) 778-8932 msmith@ciginsurance.com
License # 0F56568

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FREE Homeowner's Insurance Quote

Earthquake
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