Palo
mar Specialty Residential Earthquake Application
Date:
Agen
cy Information
:
Agency Name: Agency Contact:
Phone: Fax: E-Mail Address:
Mailing Address: ____________________________________City/State: Zip: ________________
Applic
ant Information
:
Name
d Insured: __________________________________DOB: ____________________________
Phone: _________________________________________ E-mail Address:
Phys
ical Address: _______________________________________________________________________________
City/S
tate: ________________________________________________ Zip: _________________
Mailing Address (if different than the insured location):
City/State: Zip: _______________
Home
owners Coverage / Limits of Liability
:
Homeowners Carrier: Current Policy Expiration Date: ____________________
Dwelling: $ Other Structures: $
Contents: $__________________________________________ Loss of Use: $
Year of Construction: _______________________ Square Footage: _____________________ Number of Stories: _____________
Type of Construction (e.g., Wood Frame, Wood with Masonry Veneer, Masonry, etc.): _____________________________
Foundation Type (e.g., concrete slab, basement, cripple wall, etc.):
Prior Earthquake Damage: Yes No (If yes, proof of repair is required)
Has coverage has been cancelled or
denied in the last three years?
Yes No If yes, please provide reason why:
Grade Under Dwelling (Flat is 0 degrees, Gentle is less than 20 degrees, Steep is greater than 20 degrees) _________________
