Mizuno Insurance Agency

Mizuno Insurance Agency
 
California Insurance License Number 0E83160

HOME INSURANCE QUESTIONNAIRE  (for Renters)

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

  

Name
Property Address
City
Zip Code
Is mailing address different from address above? if yes,
Mailing Address
City
Zip Code

Phone (optional)

E-mail Address


Property Information

Any claim within 5 years  
If answer is Yes,
type of Loss
     

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 **


Coverage

Personal
Property:
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.

 


 


Designed by SAT Computer
Copyright (c) 2007,2020 Mizuno Insurance Agency. All rights reserved.
Date Time: 03-29-2023 10:15:55 PM