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First Name
Last Name
Company Name
Address Line 1
Address Line 2
City
State
Zip Code
Cell Phone
Daytime Phone() -
Evening Phone() -
Fax() -
E-mail Address
Type of Construction - Frame - Masonry - Tilt Up etc
Has Project Started, if so, when ?
Is the Builders name different than the named insured ?
If Different Please name
Number of Stories
Total Square Footage
Type of Project (Commercial Cntr, SF Residence, Hotel, Ind. Bldg)
Property Address / City / Zip / Cnty
Value of all Covered Property
Deductible 1000 - 5000 - 10,000
Estimate Lenght of Project
Type of Business - Ind - Corp - Partnership - Jt. Venture
Coverage Amount requested for any one structure
Any coverage desired for walls, sub-division fences or signs. If yes, amount requested
Does builder have at least 2 years experience ?
Is contractor insuring more than one building within 100 feet of this project ?
Builders loss experience for the last three years - indicate any claim over 5000.00
Comments
516 Pensfield Place, Ste. 203
Thousand Oaks, CA. 91360
Business Phone (805) 379-3899
Toll Free (866) 781-BEST (2378)
 
Business Fax (805) 379-2355

 

 Jake@dginsurancegroup.com
dennis@dginsurancegroup.com
State of California License # 0E24624

 

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