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Flood & Home Quote

posted by Anonymous on Wed, 07/13/2011 - 22:34

Galaxy Insurance Service Inc
2403 East Anaheim St.
Long Beach, CA 90804
Phone (562) 438-7000 , Fax (562) 438-7001
http://www.galaxyinsurance.com/
info@galaxyinsurance.com
CA Lic #0D44460 * = required

Applicant Information

First Name *

Middle *

Last Name

Physical Address *

City *

Zip Code *

Mailing Address

City

Zip Code

Home Phone *

Alternate Phone

Year Built *

What is the Square Foot of the House *

How Many Stories *

How Many Fire Places *

How Many Garage Stalls *

Type of Insurance *

Garage Type *

Description of Property

Building Type *

Construction Type *

Occupancy *

Roof Type *

Year Update *

Is It Flat Roof? *

Yes

No

Plumbing Type *

Year Update *

Electrical Type *

Year Update *

Heating Type *

Year Update *

Other (Explain?) Heating Type

Security System

Smoke Detector

Yes

No

Central Alarm

Yes

No

Dead Bolt

Yes

No

Sprinkler

Yes

No

Any Swimming Pool

Yes

No

Diving Board

Yes

No

Slide

Yes

No

Type of Fence

Any Animals

Yes

No

Animal Type

Kind of Animal

Any Claim Within 36 Months *

Yes

No

Type

Amount Paid $

Closed or Open

Coverage

Building Amount $

Limit of Liability *

Medical Payment

Personal Property *

*For Renter, Condominium & Flood Only

Deductible Amount *

Foundation *

Additional Information or Comment

Email Address *

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