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BUSINESS EARTHQUAKE INSURANCE: DIC (Difference In Conditions) plus Earthquake. This "stand-alone" program provides coverage for personal, business and commerical buildings and contents up to $50,000,000 and more in value. Coverage is available for dwellings (as a stand alone product), High Rise Multi Story Buildings (Residential & Office), Condo Associations, Apartment Buildings, Shopping Centers and more. Please complete the Earthquake Worksheet below to receive an insurance proposal.

We have other insurance program worksheets you can select from the InsuranceCompany.com main menu option or clicking on the InsuranceCompany.com logo to the right. Comprehensive programs. We specialize in hard to place individuals, groups and companies. If you need earthquake coverage for your home in combination with your fire policy please select the homeowners option. If you need flood insurance coverage for your dwelling, property or business please select the flood option. If you need earthquake coverage for your mobilehome in combination with your fire policy please select the mobilehome option.

EARTHQUAKE WORKSHEET
First Name:
Last Name:
Business Name:
Mailing Address:
Mailing City:
Mailing State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington West Virginia Wisconsin Wyoming
Mailing Zip Code:
Phone Number:
Fax Number:
E-Mail Address:

PROPERTY INFORMATION
Property Address:
Property City:
Property State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington West Virginia Wisconsin Wyoming
Property Zip Code:
Occupancy Type:	Owner  Tenant  Vacant  Owner & Tenant
Building Type:	House  Condo - Contents  Townhome  Apartment Building  Office Building  Condo Assoc Complex  High Rise Building  Manufacturing Building
Year Built:
How Many Stories:	1  2  3  4  5  6  7  8  9  10  More Than 10 Stories
Total Square Footage of the Building:
How Many Units Are In The Building:
Garage Description:	No Carport - Garage  Car Carport - Attached  Car Carport - Detached  Garage - Attached  Garage - Detached  Tuck Under Parking  Above Ground Parking  Below Ground Parking  Parking Lot  Street Parking
Construction Type:	Frame  Masonry Veneer  Masonry  Superior
Foundation Type:	Piers  Wood  Stilts  Posts - Pilings  Basement  Masonry  Rubble Stone  Non-Reinforced Concrete  Craw Space - Concrete Perimeter  Craw Space - Wood Perimeter  Flat Slab-Poured Reinforced Concrete
Nature of Sub-Soil:	Sand  Clay  Rock  Marsh  Filled Land  Unconsolidated Ground  Natural Consolidated Ground
Topography:	Flat  Cliff  Terraced  Steep Hill  Gentle Hillside  Under 100ft to Water  Hillside Over 30 Degrees
Roof Type:	Tile  Slate  Metal  Woodshake  Composite Material
Roof Updated:	yes no
If Yes, Year Roof Updated:
Any Erosion in the Area?	yes no
Any Below Ground Parking?	yes no
Any Soft First Story or Tuck Under Parking?	yes no
Protection Distance:	1000 ft or less to a hydrant & 5 mi or less to a fire station  Over 1000 ft to a hydrant & 5 mi or less to a fire station  Over 5 & up to 10 mi to a fire station  Over 10 mi to a fire station
Is the Building in the Brush Area?	yesno
Is there a Brush Hazard within (1) mile of the Building?	yesno
If yes, has the Brush been cleared by 250 feet from all sides of the Building?	yesno
Smoke Detectors:	yesno
Fire Extinguishers:	yesno
Electrical Updated:	yes, recently updated no
Circuit Breakers:	yes no
Heating - Air Conditioning, How Old?
Plumbing Updated:	yesno
If Yes, Year Plumbing Updated:
Copper Plumbing:	yes no
Automatic Sprinklers:	None Partial full
Fire Alarm:	None Local
Earthquake Retrofitted or Bolted:	Yes   No, Building is Not Bolted  Yes, Recently Bolted or Retrofitted for EQ
Current Insurance Company:
Losses-Claims in the last 5 years:	None  One  Two  Three  Four  Five
If Yes, Date, Amount Paid and Description of each Loss-Claim

COVERAGE INFORMATION
Building Coverage:
Other Structures Coverage:
Contents Property Coverage:
Loss of Use Coverage:
Earthquake Deductible:	5% 7.5% 10% 15% 20% 25% 30%
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