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* Street Address:

* City:   * State:   *Zip:

* Home Phone:           Cell Phone:   * Email:

Best Time to Contact You:    AM    PM

Check box for:   Primary Home  Dwelling   Condo   Townhouse

Usage:   Primary Home   Seasonal    Rental    Vacant    Other use

Years lived at Address to be insured:     New Purchase    1-5 years  Over 5 years

California Homeowners Insurance Coverage & Limits of Liability:   

Policy Deductible select either:  

Dwelling Information:    Year House Built     Square Feet    

1 Story   2 Story          Garage size: 1 car  2 car 3 car  More

Roof type:  Composition    Wood shake     Tile     Metal    Other

  Yes   No

Loss History:    Date(mm/yy)   Amount of Loss:

Additional Services You Require:          

Discounts available for:
Law Enforcement, Fire Fighters, Teachers, Physicians, Medical Staff, Public Utility employees, CalTrans employees, PERS members, STRS members, Current or Retired City, County, State employees, Current or Retired Military. Discounts also available for auto and home package.

Yes No    If Yes, Which of the above apply?

    

      

Barragan Insurance