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Step One: Complete Form
Step Two: Review and Submit
Step Three: Finish
Welcome to Earthquake E-Z Quote from A&M.
For fast service on your brokerage earthquake accounts complete the form below and hit the “Step Two” button. Your submission will be electronically delivered to the next available Brokerage Underwriter.
 
Applicant Name:
Applicant Website Address:
Location address:
City: State: Zip Code:
Description of Risk:
Expiring Carrier:
 Willing to Renew?:
Renewal Quote:
$ 
Target Premium:
 $ 
Deductible:
Property Information
Building:
 $ 
Contents: $ 
If Apt, # of units:
 Building Shape: 
Square Feet:
Construction Type:
Loss of Income:
 Number of Stories:
Tenancy?:
 Primary Occupancy:
Parking Type:
  
 
If over 20 years old, provide building updates: Building Updates / (Year)
Year Built: Wiring (Yr):   Roof (Yr):   Heating/Air (Yr):   Plumbing (Yr):
Setbacks/Overhangs:
Building on 100% curcuit breakers?:
Earthquake sprinkler leakage?:
Mold clean-up and removal?:
    Comments & other Material Information:
     
Agency Name:
Contact Person:
Phone Number:
   Fax Number:
E-mail Address:
  
 
    (You will get a summary page to review before submitting)