(714) 751-4610
Costa Mesa, CA
Clarke Insurance Agency
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Home Quote
Contact Name
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Email
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Phone Number
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Date of Birth*
Occupation
Property Location
Address
City
State
Zip Code
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County
How did you find our agency?
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Current Insurance Information
Company Name
Current Annual Premium
Expiration Date
Insurance Information
Deductible Desired
$100
$250
$500
$1000
$1500
$2000
$2500
$5000
Amount of Liability Desired
$100,000
$500,000
$300,000
$200,000
$1,000,000
Earthquake Coverage Desired?
Yes
No
Windstorm Coverage Desired? (not applicable in all states)
Yes
No
If Any Pets, What Breed?
Dwelling Information
Is this home owner occupied or a rental?
Owner Occupied
Rental
Estimated Replacement Cost
Square Footage
Year Constructed
Is Your Home over 20 Years Old? If so, What Updates Have Been Made?
Age of Hot Water Heater?
Roof Type and Age?
How Many Floors?
1 Story
1.5 Story
2 Story
Bi-Level
Tri-Level
Other
Type of Construction
Wood
Stucco
Masonry
Brick Veneer
Aluminum Siding
Other
Other Home Features
(check all that apply)
Dead Bolts
Smoke Detectors
Fire Extinguisher
Central Station Fire Alarm
Central Station Burglar Alarm
Located within 5 miles of Fire Station
Located 1000 feet from Fire Hydrant
Swimming Pool
Trampoline
Home Located within City Limits
Claims
List any claims in past 3 years:
Date of Claim
Amount Paid
Claim Type
Description
Date of Claim
Amount Paid
Claim Type
Description
Date of Claim
Amount Paid
Claim Type
Description
Personal Property
Estimated value of your personal property:
Jewelry & Watches
Furs
Silver
Firearms
Stamp and Coin Collections
Fine Arts and Breakable Items
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