Mizuno Insurance Agency

Mizuno Insurance Agency
 
California Insurance License Number 0E83160

HOME INSURANCE QUESTIONNAIRE  (for Home Owner)

Please provide the following contact information:
ALL QUESTIONS THAT ARE APPLICABLE MUST BE ANSWERED

  

Name
Mailing Address
City
Zip Code
Current Ins. Co.
Current Ins. Expiration Date (Format Month/Day/Year; mm/dd/yyyy)
Primary Phone #
E-mail Address


Property Information

Property Address
City:
Zip Code:
Type of Property    
Any claim within 5 years  
If answer is Yes,
type of Loss
     
Year Built:
Type of Roof:      
Type of Exterior:    
Is Residence:I  
Living Area Sq. Feet
How many Bedrooms
How many Bathrooms Full  Half  Three Quarter
Breezeway / Balcony:  SQ Footage
Garage Size:    
Garage Type:
Any Extra Structure      
 Is Your Patio     SQ Footage
Wood Decks  SQ Footage
Fire Place     How many? 

Do you have any PETs?

 

If pet is a dog:

How many?  
what type of breed  
Any bite history?  
Any type of formal training?  


Any discount

Burglar Alarm:  
Fire Alarm:  
** Proof Required Later **


Property Upgraded Information

Roof Updated:   year
Wiring Updated:   year
Heating Updated:   year
Plumbing Updated:   year


Coverage

Liability:
Medical:  
Deductible:          


Remarks

 


Note: IF YOU HAVE ANY VALUABLE ART WORK  EXTENSIVE AMOUNTS OF JEWELRY, THESE ITEMS SHOULD BE INSURED SEPARATELY,  OTHER ITEMS AND COLLECTABLES SHOULD ALSO BE INSURED SEPARATELY, WE WILL ADVISE YOU OF THESE ITEMS AT A LATER DATE.

 


 


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Date Time: 04-26-2018 06:32:25 AM