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Quote Request for Homeowners Insurance
Please answer all questions to prevent a delay in processing your quote request.
If you have any questions call us at 408.286.1111 for help or fax at 408.997.7890
Contact Information
Contact Person:

Date of Birth:/ / mm / dd / yyyy
Property Address:


Telephone: Cell Phone:
Home Phone: Fax:
Email Address:
Best Time to Contact:
Send Quotes via:
Additional Information
Are you currently insured?
Yes No
Type of Property:
Occupancy (check all that apply): Owner Occupied
Rented to Others
Second Home/ Vacation
Number of Claims on any property owned in the last 36 months?
Specific Information on the Home
Construction of Home:
Style of Home:
Number of Stories: (excluding basement)
What year was the home built?:
What type of Foundation supports the home?: Not Sure
Concrete Slab
Crawl Space
Basement (finished)
Basement (unfinished)
Roofing Material: Asphalt or Architectural Shingles
Clay or Spanish Tile
Wood Shake
Concrete Tiles
Don't know
Type of Heating:
Oil or Gas Burner replaced or updated recently: Yes No
How many amps in electrical service:
Garage Type:
Number of cars garage holds:
Security Features (check all that apply): Smoke Detectors
Fire Extinguishers
Dead Bolts
Local Burglar Alarm (rings outside home)
Local Fire Alarm (rings outside home)
Central Station Burglar Alarm
Central Station Fire Alarm (Central station means connected directly to a monitoring facility that contacts police or fire dept on your behalf)
Home Features
Central Air:
Number of Bathrooms:
# Fireplaces:
Swimming Pool:
Insurance Coverage
What is the purchase price of the home? $
Mortgage Amount $
Dwelling Amount help $
Personal Property Cov. $
Personal Liability Cov.help $
Is Earthquake Coverage Required? Yes No
Do you need coverage for scheduled personal property (jewels, furs, silver) beyond what the standard policy offers? Usually big ticket items. help: Yes No
If yes, give amt in $'s for each
example $12,000
Jewelry $
Furs     $
Silver   $
Other   $
Underwriting Questions
Underwriting questions (as you may know, credit has become a major factor in obtaining insurance in a number of states, so please be aware that where applicable, rates will be quoted based on your responses below)
Filed For Bankruptcy in last 5 years?: Yes No
Is Your Credit Rating: Good Excellent Fair Poor
Do you have a pet? Yes No
Other types of insurance you would like to see: Auto
Business Auto
Do you Smoke? Yes No
Are you a robot?


Copyright 2005-2015 Jeewanjee Insurance Agency All rights reserved

California Lic # 0697055
1494 Hamilton Ave #101, San Jose, CA 95125