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Commercial Earthquake Coverage Request Form

Important! Please make sure all of the fields in the form below are completed correctly.
We cannot send you a quote unless we have all of your information.

Contact / Insured Information  
Insured Name Last Name / Company Name
First Name
Insured Contact Name
Contact Title
Contact Phone
Contact FAX
Contact Email
Insured Interest in Building Owner / Occupant      Lessor      Tenant
Requested Effective
Date of Coverage

Mailing Address Info  
Street Address
City   State   ZIP

Agency Information (If being referred by an insurance agency)  
Agency Name
Agency Contact Name
Agency Phone
Agency FAX
Agency Email

Property Address Info  
Check this box if the mailing address and property location are the same.
Street Address
City   State   ZIP (California properties only.)

Description of Property (if multiple buildings — one form per building)  
Property Usage / Occupancy
Number of Units
(if Habitational)
Number of Buildings
Number of Levels
Soft Story / Ground Floor Mostly Parking? Yes   No
Describe Parking Help Me Choose
Original Year of Construction
Any retorfitting work done? Yes    No    Year Retrofitted:
Describe retrofitting, if any
Square Footage
On Firm Natural Soil? Yes   No
Slope within 50 ft of Structure Flat   Less 10%   10-28%   Greater than 28%
Construction Type
Foundation Type
  Describe if Other:
If Wood Frame Const. is Building Bolted to Foundation? Yes   No   N/A
Is Building Sprinklered? Yes   No
If Sprinklered — Do you want EQ Sprinkler Leakage Coverage? Yes   No   N/A
Roof Type
Additional Information

Existing Coverage 
Insurance Company
Policy Expiration Date

Coverages Requested  
Deductible requested (note ded based on % of coverage) 5%   7.5%   10%   15%   25%
  Building Coverage
  Contents (Business Pers Prop)
Loss of Rents (if Tenant Occupied)
  Business Interruption with Extra Expense
Demolition Coverage (usually 5% of Bldg)
  ICC — Increased Cost of Construction Coverage (usually 5% of Bldg)
EDP (Electronic Data Processing)
Valuable Papers
EQ Sprinkler Leakage Desired (if bldg sprinklered) Yes   No   N/A
Stop Loss Limit Desired (If any)
Other Coverage requested - Describe
Other Comments