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The Big Umbrella
Fall 2009
Summer 2009
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?:
Yes
No
No Previous Coverage
Renewal Quote:
$
Target Premium:
$
Deductible:
5%
10%
15%
Property Information
Building:
$
Contents:
$
If Apt, # of units:
Building Shape:
--Select--
Regular
Irregular
Square Feet:
Construction Type:
Loss of Income:
Number of Stories:
Tenancy?:
--Select--
Owner
Tenant
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:
Yes
No
Building on 100% curcuit breakers?:
Yes
No
Earthquake sprinkler leakage?:
Yes
No
Mold clean-up and removal?:
Yes
No
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)