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License# 0L09546
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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 earthquake accounts complete the form below and hit the "Step Two" button. Your submission will be electronically delivered to the next available Underwriter.
Applicant Name:
Applicant's Name is required!
Applicant Website Address:
Applicant's URL is required!
Location address:
Address is required!
City:
City is required!
State:
State is required!
Zip Code:
Zip Code is required!
Description of Risk:
Description of Risk is required!
Expiring Carrier:
Expiring Carrier is required!
Willing to Renew?:
Yes
No
No Previous Coverage
Willing to renew is required!
Renewal Quote:
$
Renewal Quote or N/A is required!
Target Premium:
$
Target premium is required!
Deductible:
5%
10%
15%
Deductible is required!
Property Information
Building:
$
Building is required!
Contents:
$
Contents is required!
If Apt, # of units:
If Apt, # of units is required!
Building Shape:
--Select--
Regular
Irregular
Building Shape is required!
Square Feet:
Square feet is required!
Construction Type:
Construction Type is required!
Loss of Income:
Loss of Income is required!
Number of Stories:
Stories is required!
Tenancy?:
--Select--
Owner
Tenant
Tenancy is required!
Primary Occupancy:
Primary Occupacy is required!
Parking Type:
Parking Type is required!
If over 20 years old, provide building updates:
Building Updates / (Year)
Year Built:
Year Built is required!
Wiring (Yr):
Year wiring is required!
Roof (Yr):
Year roofing is required!
Heating/Air (Yr):
Year heating is required!
Plumbing (Yr):
Year plumbing is required!
Setbacks/Overhangs:
Yes
No
Setbacks/Overhangs is required!
Building on 100% curcuit breakers?:
Yes
No
If 100% Circuit breakers is required!
Earthquake sprinkler leakage?:
Yes
No
If EQ sprinkler leakage is required!
Mold clean-up and removal?:
Yes
No
If mold clean-up/removal is required!
Comments & other Material Information:
Agency Name
:
Agency Name is required!
Contact Person
:
Contact Person is required!
Phone Number:
Agency Phone Number is required!
Fax Number:
Fax number is required!
E-mail Address:
Agency Email address is required!
Please enter a valid e-mail address!
(You will get a summary page to review before submitting)