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 Apartment Bldg. Quote 
Form:Dwelling Fire/Apartment Building Insurance Quote
Dwelling Fire/Apartment Building Insurance Quote




Contact Information
Name of Business:
Contact Name:
Address:
City:
 State: Zip:
Business Phone:
 Fax Number:
Contact Email Address:
Property Information
Address of Property:
Property City:
Property State:
Property Zip:
New purchase Existing ownership
Number of units:
Building Square footage:
Year Built:
Occupancy:
Owner Tenant
Occupancy Type:
Plumbing type:
 Copper Galvanized Mixed (Copper/Galvanized)
Foundation Type:
 Slab
Crawlspace over slab
Pier & Post
 Other (list in remarks)
Type finished basement, if any:
 None Full 25% 50% 75%
Type Roof:
 Shingle
Wood Shake
Tar/Gravel
Spanish Tile
Metal
Other
Type of Siding:
 Brick Vinyl Wood Aluminum
Number of stories:
 1 2 3 4 or more
# of feet to nearest fire hydrant:
# of miles to nearest fire station:
Currently Insured?
Name of Carrier & how long insured?
 Yes No
Coverage'ss
Building Coverage
 $
Liability Coverage
 $
Contents
 $
                      Deductible $
($250, $500, $1,000, etc.)
 $
Other Coverage/Remarks:
(describe any extra coverage's
needed such as businessinterruption,
robbery, computers, etc.):
Any claims reported on this property:
or previously owned properties in
the last 3 years?
 Yes No
Please describe: Include date(s) and:
details of claim
Additional Comments
Please give any additional comments or questions

No coverage of any kind is bound or implied by submitting information via this online form

  • Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
  • We will not distribute information to other parties other than for insurance underwriting purposes.
  • By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.

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Coast West Insurance Agency, Inc. 28310 Roadside Dr. Ste 115 Agoura Hills, CA 91301 (800) 566-3331

© Coast West Insurance Agency, Inc., 2008



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