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A Service of Simons
Insurance Agency
12743 Bellflower Blvd.
Downey, CA 90242
Toll Free: 888-646-2366
Local Phone: 562-803-3101
Fax: 800-346-2245
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On-Line Renters Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!
Your Personal Data
Your Name
Property Address
City
State: (Must be California)
Zip Postal
E-Mail (REQUIRED)
E-Mail (again for accuracy)
Phone
Fax (optional)
Dwelling Information
Year Dwelling Built
Home Square footage:
# Units in common bldg.
Type Roof
Shingle      Wood Shake
Tar/Gravel      Spanish Tile
Number of stories
One      Two
Three      4+
Do you own animals or pets?
If yes, list type/for dogs, list breed
Yes      No
Are You Near Brush Area?
Yes      No
# of feet to nearest fire hydrant
# of miles to nearest fire station
Currently Insured?
Name of Carrier & how long insured?
Yes      No
Prior Claims?
Describe claims in detail
Yes      No
Plumbing type
Copper      Galvanized
Mixed (Copper/Galvanized)
Circuit Breakers or fuses?
Breakers      Fuses
# Fireplaces     
# Chimneys     
Special features
(i.e., deck, air conditioning, alarm systems, pool, etc.)
Coverages
Contents $
Loss of Use $
Liability Cov. $
Deductible $
($250, $500, $1,000, etc.)
Comments/Remarks
(describe any scheduled jewelry, in-home business, or other special coverages needed here)
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E-Mail                  Fax
Regular Mail      Call Me By Phone
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