CONDOMINIUM OWNERS / RENTERS QUESTIONNAIRE

Applicant Name:

Type of Quote Desired:
Property Address:
City / State / ZIP
Telephone/FAX:
Email:
Date of Birth / Occupation

Mailing Address:
City / State / ZIP
Personal Property
Coverage Desired
Year Built of Building Square Footage of
Unit or Home
Number of Units
In Building
Number of Stories Type of Roof Sprinklers?

Yes   No

Central Station Alarm for Fire and/or Burglary

Any Claims in the Last 3 Years

Yes   No

Yes   No

To Submit Request:
-- Complete Form, Print then
 FAX to (415) 454-8311
 or



Please Note: Our Agency Will Contact You Within the Next Business Day After Submitting REQUEST


Full-Service Insurance Agency
817 Mission Avenue - San Rafael - California 94901
Tele. (415) 454-0100 - FAX (415) 454-8311 - Toll Free (888) 822-4INS(4467)
WWW.MichaelMillerInsurance.com
California Insurance License 0541868

Applicate_name: condo renters
Applicate_name0: test
property_address: test
city_st_zip: test
tele_fax:
email_address:
date_of_birth_occupation:
mailing_address:
city_st_zip0:
Personal_Property_Coverage_Desired:
Year_Built:
Square_Footage:
Number_of_Units:
Number_of_Stories:
Type_of_Roof:
Sprinklers_yes:
Sprinklers_no:
Central_alarm_yes:
Central_alarm_no:
Claims_yes:
Claims_no:
Submission: Submit information via email
HTTP User Agent: Mozilla/4.0 (compatible; MSIE 7.0; Windows NT 5.1; Trident/4.0; FunWebProducts; .NET CLR 1.1.4322; .NET CLR 2.0.50727; .NET CLR 3.0.4506.2152; .NET CLR 3.5.30729)
Date: 21 Nov 2011
Time: 16:41:58


Applicate_name: test web-Joy
Applicate_name0: condo owners/renters
property_address:
city_st_zip:
tele_fax:
email_address:
date_of_birth_occupation:
mailing_address:
city_st_zip0:
Personal_Property_Coverage_Desired:
Year_Built:
Square_Footage:
Number_of_Units:
Number_of_Stories:
Type_of_Roof:
Sprinklers_yes: ON
Sprinklers_no:
Central_alarm_yes: ON
Central_alarm_no:
Claims_yes: ON
Claims_no:
Submission: Submit information via email
HTTP User Agent: Mozilla/4.0 (compatible; MSIE 7.0; Windows NT 5.1; Trident/4.0; FunWebProducts; .NET CLR 1.1.4322; .NET CLR 2.0.50727; .NET CLR 3.0.4506.2152; .NET CLR 3.5.30729)
Date: 02 Dec 2011
Time: 11:10:21


Applicate_name: Sanny Ryan
Applicate_name0: HO6 (per Kristi Wells)
property_address: 700 Illinois Street, #202
city_st_zip: San Francisco, CA 94107
tele_fax: 415-863-1734
email_address: sanny721@yahoo.com
date_of_birth_occupation: 07/21/1976 / CPA
mailing_address: same as above
city_st_zip0:
Personal_Property_Coverage_Desired: 50000.00
Year_Built: 2002
Square_Footage: 1500
Number_of_Units: 20
Number_of_Stories: 5
Type_of_Roof:
Sprinklers_yes: ON
Sprinklers_no:
Central_alarm_yes: ON
Central_alarm_no:
Claims_yes:
Claims_no: ON
Submission: Submit information via email
HTTP User Agent: Mozilla/5.0 (Windows NT 6.1; WOW64; rv:10.0.2) Gecko/20100101 Firefox/10.0.2
Date: 19 Mar 2012
Time: 15:53:38


Applicate_name: RVP Investments
Applicate_name0: Condo owner intending to rent unit
property_address: 76 Ross Avenue#13
city_st_zip: San Anselmo, CA 94960
tele_fax: (44) 208 882 1428
email_address: rvp76@btinternet.com
date_of_birth_occupation: 02/08/1946, part time university tutor
mailing_address: 147 Pasteur Gardens,
city_st_zip0: London N18 1AH, UK
Personal_Property_Coverage_Desired: none
Year_Built: 1985
Square_Footage: 881
Number_of_Units: 13 but in blocks
Number_of_Stories: 2
Type_of_Roof: artificial felt-type tiles
Sprinklers_yes:
Sprinklers_no: ON
Central_alarm_yes:
Central_alarm_no: ON
Claims_yes:
Claims_no: ON
Submission: Submit information via email
HTTP User Agent: Mozilla/5.0 (compatible; MSIE 9.0; Windows NT 6.0; Trident/5.0)
Date: 13 Apr 2012
Time: 09:28:33


Applicate_name:
Applicate_name0:
property_address:
city_st_zip:
tele_fax:
email_address:
date_of_birth_occupation:
mailing_address:
city_st_zip0:
Personal_Property_Coverage_Desired:
Year_Built:
Square_Footage:
Number_of_Units:
Number_of_Stories:
Type_of_Roof:
Sprinklers_yes:
Sprinklers_no:
Central_alarm_yes:
Central_alarm_no:
Claims_yes:
Claims_no:
Submission: Submit information via email
HTTP User Agent: Mozilla/5.0 (compatible; MSIE 9.0; Windows NT 6.1; WOW64; Trident/5.0)
Date: 19 May 2012
Time: 15:04:49


Applicate_name: Elisabeth Kleinbub
Applicate_name0: HO-6
property_address: 555 Pierce
city_st_zip: Albany, CA 94706
tele_fax: 510 5589119
email_address: ezkam@aol.com
date_of_birth_occupation: 7/23/61; Health Director
mailing_address: 939 Solano
city_st_zip0: Albany CA 94706
Personal_Property_Coverage_Desired: 50,000
Year_Built: 1977
Square_Footage: 1090
Number_of_Units: 479
Number_of_Stories:
Type_of_Roof:
Sprinklers_yes: ON
Sprinklers_no:
Central_alarm_yes:
Central_alarm_no:
Claims_yes:
Claims_no:
Submission: Submit information via email
HTTP User Agent: Mozilla/5.0 (compatible; MSIE 9.0; Windows NT 6.1; WOW64; Trident/5.0)
Date: 19 May 2012
Time: 15:07:10