Name of Homeowner(s) on title:
Property Address (include city and zip):
Mailing Address (if different):
Is your home in the name of a trust or business name?
Date of Birth:
Mobile/ Manufactured/ Modular home
Is this home currently insured:
Yes (please provide current declaration page of your policy)
Is this new home purchase currently in escrow?
If yes, estimated closing date?
# of stories:
# of residents in the home:
Is there an outdoor pool/Jacuzzi:
Foundation Type (check all that apply):
Crawl Space (you can crawl under home)
Stilts/ pilings/ other
Built-in (living space above garage)
# of cars garage holds:
Any dogs live in the home:
If yes, please specify quantity and breed:
List any unusual or exotic pets:
List any unique features of home:
Is it a gated community:
Is there a 24 hour security guard shack at the entrance or a 24 hour security patrol that drives around:
Is your home part of an HOA (Homeowners Association):
Central Station Alarm:
Any claims in the last 3 years:
Do you have any workers in the home (caretaker, housekeeper, nanny etc.):
If yes, approximate hours per week:
In home business which creates foot traffic to your home?
In home fire sprinkler system (usually in new homes only):
Is there a fire station within 5 miles and a fire hydrant within 1000 feet:
Year roof was replaced/repaired/inspected:
Is your home built prior to 1970?
Not Sure/ Other
Year electrical system was replaced/repaired/inspected:
Year Plumbing system was replaced/repaired/inspected:
Not Sure/ Other
Year heating system was replaced/repaired/inspected:
Solar panels on the roof?:
If new purchase, is the plan to occupy the home within 30 days of starting this policy:
If new purchase, will there be any renovations at this home before you move in:
If so, please describe:
Earthquake and flood are never covered under a home policy but can be written separately. Would you like a free quote?
Any questions or comments?
Doctor & Doctor Insurance Agency
10216 Reseda Blvd, Northridge, CA 91324
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