HOMEOWNER / LANDLORD QUESTIONNAIRE

Applicant Name:

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

Mailing Address:
City / State / ZIP
Current Building Coverage Year Built Square Footage Number of Units
Number of Stories Age and Type of Roof Type and Size of Garage 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