Class Act Insurance Services

Condo Insurance Quote Request
Best Viewed in 800x600 Screen Resolution

Reason for insurance request:
New purchase Current owner with no prior insurance
They are Cancelling my Account Account is going to Non-Renew Searching for a better price

First Name*:

Last Name*:

Property Street Address*:

Apartment Number/ Unit:

City*:

State:

Zip Code*:

Home Telephone*:

Work Telephone:

Fax Telephone:

Email Address:

Martial Status*: Occupation:

Prior Insurance company Expiration: Example 08/20/1970

Property Information

Is the property occupied by : Owner or Tenant
Type of Dwelling

Year Built : Square Feet: # of Families at residences:

Years at residence:

# of stories/floors:

# of bathrooms: ( Please include any special items, such as marble or hot tubs)

Type of Foundation:

Type of Roof:

Distance to Fire Hydrant: List any dogs: (Include type of breed)

Distance from any brush hazard: (List distance in feet please)

Types of renovation		Year	Date Partial repair	Date Completed
Wiring	None
Plumbing	None
Heating	None
Roofing	None
Exterior Paint	None

Additional Underwriting Questions

1. Is the dwelling currently full time occupied by insured or will be within 10 days from inception of coverage?	Yes No
2. Does insured have any open claims/losses paid in excess of $5000 within the last 24 months OR losses in excess of $2,500 OR multiple(3) small claims within the last 12 months or repetitive similar cause losses? If yes please describe:	Yes No
3. Is dwellings owned/titled under business or with more than 2 mortgagees, or any type of business performed on premises including child care? If yes please describe:	Yes No
4. Does insured have vicious dog(s) or dogs with bite history or farm animals where animal liability is purchased? If yes please describe:	Yes No
5. Does dwelling have a wood burning stove that doesn't meet current building codes or stove with reclaiming heat devices or inadequately maintained? If yes please describe:	Yes No
6. Is unit mobile homes/trailer/modular home/portable home or home witout utility services or home with pool/spa that is incompliant with built code or inproperly fenced? If yes please describe:	Yes No
7. Is dwelling located in or near (within 1/4 mile) brush fire/landslide/forest areas or built on piers/pilings or not on solid/permanent foundation? If yes please describe:	Yes No
8. Is dwelling under construction or extensive remodeling, renovation or with unprepared damage from previous claim? If yes please describe:	Yes No
9. Does dwelling have copper pipes and copper wire with circuit breakers? If yes please describe:	Yes No

Report Claims

Please describe any claims made in the last 3 years. Check here if None
(Include dates, type, and amount paid out)

Levels of Coverages

Personal Property Coverage: $ Please list amount of coverage desired.

Liability:*

Coverage Limit Per Occurence

Deductible:*

Guest Medical Payments Coverage:*

Addition Comments:

Please let us know the best time to contact you?

Referred by:

IMPORTANT NOTE: This form is provided as a convenience to you. We will make a good faith effort to obtain competitive quotes for your review. Depending on the type of business, we may require more information and will contact you if necessary. Your submission of this form DOES NOT guarantee that any binding offers will be forthcoming from insurers we represent.

Class Act Insurance Home Page