Prime Insurance Services - Auto, Home, Commercial, Life and Health Insurance for California Residents

Contact/Property Information

Contact Name:

*

Property Address:

*

City:

*

State:

*

Zip Code:

*

Daytime Phone:

*

Alternate Phone:

Email:

*

Smoker:

*

Yes

No

Current Age of the Owner:

Best Time to Contact:

Currently with Farmers?

Yes

No

If Yes,Policy Number

Property Information

Number of Floors:

*

Square Feet of House:

*

Number of Bedrooms:

*

Number of Bathrooms:

*

Fire Place:

*

Garage:

*

Central Air Conditioning:

*

No

Yes

Electrical System:

*

Stove Type:

*

Gated Community:

*

No

Yes

Smoke Detectors:

*

No

Yes

Dead Bolt Locks:

*

No

Yes

Fire Extinguisher:

*

No

Yes

Alarm System:

*

Your Policy Information

When do you need insurance by:

*

How long have you lived at present address:

*

If you have coverage now, who is the insurance company:

*

Is your policy being cancelled or not renewed:

*

No

Yes

If you are being canceled or have any reported claims in the last Five years, please briefly explain why reason/date/description/amount paid /claim opened or closed):

*

Desired Deductible:

*

Liability Amount:

*

Medical Payments:

*

Do you need jewelry coverage:

*

No

Yes

To receive a larger discount would you consider also insuring your cars:

No

Yes

Do you need an Umbrella Policy:

Questions or Suggestions?: