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  • Homeowner - Residence, Luxury Vacation Homes, Low Value Homes
  • Renter - Theft, Fire, Liability
  • Tenant Occupied -Protect your rentals
  • Motor Homes - Prevent the unforeseen
  • Mobile Homes - Residence or Vacation Mobiles
  • Flood Insurance - In Humboldt County . . . A Wise Decision
  • Earthquake Insurance - A Must!
Name *
Physical Address
City   State   Zip
Mailing Address
City   State   Zip
Home Phone *   Work Phone
Email (required)
Your Age

 
Have you had continuous coverage for at least 12 months?
Yes No
 
If not, why not?
 
Present
Insurance Co.
Present Coverage Amount
Renewal Date
Occupation
Claims in Last 3 Years 0123 4+
Type of Loss Amount Paid
Square Footage of Living Space
Year Home Was Built
Number of Acres Distance from Fire Hydrant (feet)
How Many Miles to Fire Department
Do you have any pets? Yes No
 Dogs(s) Horse  Other Breed of Dog
If Yes to Dogs, Is there a Biting History? Yes No   If Yes, How Many

Type Construction
1-Story
1 1/2-Story
2-Story
Split Level
Bi-Level		 Frame or Stucco
Masonry Veneer
Masonry
Foundation
Roof
Basement
Crawl Space
Slab
Post/Pier
 Asphalt Shingle
Wood Shingle
Tile or Slate
Other
Age of Roof
If you home is over 30 years old please provide information about when updates were made to:
Plumbing
Heating / HVAC
Electrical

Garage Bathrooms
1-Car
2-Car
3-Car
4-Car		 Attached
Detached
Basement
Built-in
Car Port		 # of Full
12345

# of Half
12345
Other Features
 Central Air Conditioning  Central Vacuum
 Wet Bar  Whirlpool Tub
Security System
Other Outbuildings
Barn Garage
Other    
Type Size

Fireplaces Basement
Number of Chimneys
12
Woodstove or Fireplace Insert
Yes No
Finished  Yes No
Sq. Ft.

Deck, Porch, Patio
Deck sq. ft.
Screened
Patio sq. ft.
Porch sq. ft.
Enclosed Porch sq. ft.
Comments
 

 

For More Information Contact sheila@jdinsurance.com

Judy Davis Insurance Services, Inc.
California License 0F41787
Nevada 599512
Oregon 215361