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HomeOwner Insurance
General Questions
First Name:
Middle Name:
Last Name:
How Did You Hear About Us:
Birth Date (mm/dd/yyyy):
Marital Status:
Email:
Confirmemail:
Address (where You Live):
City:
State:
Zip Code:
Home Phone No:
Cell Phone No:
Fax No:
Driver's License Number:
Questions About The House
Total Living Area (sq. Ft.)::
Estimated Value:
Year Built:
Number Of Units:
How Long Have You Lived In This Home? :
What Part Of The Year Is The Home Occupied?:
How Would You Describe The Road Or Street Access To Your Home?:
Do You Have Any Livestock Or Exotic Pets?:
Do You Have A Dog?:
Is Business Conducted On The Premises?:
Have You Experienced Any Losses Or Claims Within The Last 5 Years?:
House Safety Information
Is Your Home Located Within 1000 Feet Of A Fire Hydrant?:
What Is The Distance Of Your Home From The Nearest Fire Station?:
If Your Home Is Susceptible To Flooding Or High Water, Select The Distance To The Body Of Water In Feet. :
Do You Have A Fire Extinguisher?:
Do You Have Smoke Detectors?:
Do You Have Deadbolts?:
Do You Fire Sprinklers?:
Do You Fire Alaram?:
Do You Theft Alaram?:
Coverage Requested
Liability Coverage Amount:
Medical Payments:
Deductable:
Comment:


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Corporate Office
11201 Washington Blvd.
Whittier, CA 90606
Tel: (866) 999-9AIS
(562) 692 0506
Fax: (562) 695-6665
Email: accuraterateais@yahoo.com
Website: www.accuraterateais.com