Name Phone 6650 Reseda Blvd Suite #108 Reseda, CA 91335 contact@gisinsure.com		VACANT PROPERTY INSURANCE   First Name: Last Name: Phone Number: Fax Number: E-Mail Address: Who Referred You To Our Site? PROPERTY INFORMATION   Property Address:   Property City: Property State: Select... Alaska Alabama Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Property Zip Code: How Many Months Has The Property Been Vacant? What Date Did The Property Become Vacant? Why is the Property Vacant? What Steps have you taken to make sure the Property is safe and secure? Give a Good Description Regarding the Physical Condition of the Property? How Many Months Will The Property Be Vacant? How Many Units Are In The Building: Year Built: Date You Purchased The Property: Garage Description: No Carport - Garage  1 Car Carport - Attached  2 Car Carport - Attached  1 Car Carport - Detached  2 Car Carport - Detached  1 Car Garage - Attached  2 Car Garage - Attached  3 Car Garage - Attached  1 Car Garage - Detached  2 Car Garage - Detached  3 Car Garage - Detached    How Many Stories: 1  2  If Two Stories, Ground Floor Square Footage:   Total Square Footage of The Building:   Construction Type: Frame  Masonry Veneer  Masonry  Superior    Roof Type: Tile  Slate  Metal  Woodshake  Composite Material    Roof Updated: yes no   If Yes, Year Roof was Updated: Property Topography: Flat Land  Next To A Cliff  Terraced (Sloped)  On A Hill Under 15%  On A Hill 16-30%  On A Steep Hill Over 30%  Gentle Hillside   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? yes  no   Is there a Brush Hazard within (1) mile of The Building? yes no   If yes, has the Brush been cleared by 250 feet from all sides of The Building? yes no   Smoke Alarm: yes no Fire Extinguisher: yes no   Deadbolts: yes no Electrical Updated: Yes, Recently Updated  No  Circuit Breakers: yes no Copper Wiring: yes no Heating - Air Conditioning, How Old?: Heating - Air Conditioning, Thermostatically Controlled?: yes no  Energy Source:  Gas  Electrical  Heating - Air Conditioning, Central? yes no  Plumbing Updated: yes no If Yes, Year Plumbing was Updated: Copper Plumbing: yes no   Interior Automatic Fire Sprinklers:  None  Partial  Full  Theft Alarm: None  Local  Central  Fire Alarm: None  Local  Earthquake Zone: Earthquake Retrofitted:  Not Required, Home Built After 1975  Yes, Recently Bolted-Retrofitted for EQ  No    Fire District: Current Insurance Company: Any Dogs on the Property: yes no If Yes, Number & the Breed of Each Dog:   Any Other Pets-Animals on the Property: yes no   If Yes, Number & Description of Each Pet-Animal: Losses-Claims in the last 5 years:  None  One  Two  Three  Four  Five    If Yes, Date, Amount Paid & Description of Each Loss-Claim    COVERAGE INFORMATION Dwelling Amount (Coverage A):   Other Structures (Coverage B): Personal Property (Coverage C): Loss of Use (Coverage D): Premise Liability (Coverage E): $300,000  $100,000  $500,000  Policy Deductible: 100  250  500  750  1000  2500  5000  If EarthQuake insurance is requested, select Deductible Percentage %: No EarthQuake Coverage  10%  15%  20%  25%  30%