AFFIRMATIVE INSURANCE SERVICES

5624 Lankershim Blvd., North Hollywood, Los Angeles, California-91601.
Phone: 818-997-7879 Fax: 818-997-7844 EMAIL: info@getais.com

HOMEOWNERS WORKSHEET

First Name:
Last Name:
Phone Number:
Fax Number:
E-Mail Address:   
Birthdate
Social Security
Who Referred You to Our Site?

PROPERTY INFORMATION
 

Property Address:

  

Property City:
Property State:
Property Zip Code:
Dwelling Type:  
Number Of Bedrooms:
Number Of Bathrooms:
Number of Fireplaces:
Garage Description:  
Year Built:
Date You Purchased Your Home:
How Many Stories:
If Two Stories, Ground Floor Square Footage:  
Total Square Footage of Your Dwelling:  
Construction Type:  
Roof Type:  
Roof Updated: yes no 
If Yes, Year Roof was Updated:
Does The Dwelling Have A Pool? yes no 
If Pool, Is It Fenced? yes no 
If Pool, Is There A Diving Board? yes no 
If Pool, Is There A Slide? yes no 
Property Topography:  
Foundation Type:  
Protection Distance:
Is Dwelling in the Brush? yes no 
Is there a Brush Hazard within (1) mile of Your Dwelling: yes no 
If yes, has the Brush been cleared by 250 feet from all sides of Your Dwelling?yesno 
Smoke Alarm: yesno
Fire Extinguisher: yesno 
Deadbolts: yesno
Electrical Updated:
Circuit Breakers: yes no
Copper Wiring: yes no
Heating - Air Conditioning, How Old?:
Heating - Air Conditioning, Thermostatically Controlled?: yesno 
Energy Source: 
Heating - Air Conditioning, Central? yes no 
Plumbing Updated: yesno
If Yes, Year Plumbing was Updated:
Copper Plumbing: yes no 
Interior Automatic Fire Sprinklers: 
Theft Alarm:
Fire Alarm:
Earthquake Zone:
Earthquake Retrofitted:   
Fire District:
Current Insurance Company:
Expiration Date of Current Insurance Policy:
Any Dogs on the Property: yes no
If Yes, Number & the Breed of Each Dog:  
Any Other Pets-Animals on the Property: yes no 
If Yes, Number & Description of Each Pet-Animal:
Losses-Claims in the last 5 years:   
If Yes, Date, Amount Paid & Description of Each Loss-Claim 

  

COVERAGE INFORMATION
 

Dwelling Amount (Coverage A):

  

Other Structures (Coverage B):
Personal Property (Coverage C):
Loss of Use (Coverage D):
Premise Liability (Coverage E):
Policy Deductible:
If EarthQuake Insurance is Requested, Select Deductible Percentage %:  
Dwelling Replacement Cost Coverage: yesno 
Contents Replacement Cost Coverage: yesno
Questions or Comments
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Thank you for your interest.