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Lighthouse Santa Cruz

CREATING PEACE OF MIND
SINCE 1964

Important: Please Complete the Form in One Sitting

This form cannot be saved and completed at a later time. Please make sure you have enough time to complete all required fields before you begin. Your progress will not be saved if you leave the form before submitting it.

Home Insurance New Business

DOB:
Month
Day
Year
Date of Purchase (best estimate):
Month
Day
Year
Primary Home:
Yes
No
If no:
Landlord
Vacant
2nd Home
VRBO/AirBnB
Renewal/Cancellation Date:
Month
Day
Year
Reason for requesting this quote:

We must receive the above requested documents within 48 hours of receiving your home information in order to submit out to our markets.

Garage:
Attached
Detached
Built-In
No Garage
Sprinklers:
Yes
No
Fireplace:
Yes
No
Wood Burning Stove:
Yes
No
Propane Tank:
Yes
No
Alarm:
Yes
No
Roof Type:
Comp/Asphalt Shingle
Tile
Metal
Clay
Wood
If roof is comp/asphalt shingle:
Architectural Shingle
3 Tab Comp Shingle
Luxery Comp Shingle
Pool:
Yes
No
If yes, is pool fenced:
Yes
No
Foundation:
Full Perimeter Foundation with Crawlspace
Concrete Slab
Pier & Beam
Basement
Other

Interior flooring material. (Percentage of total flooring area must equal 100%).

Type of house siding:
Wood
Stucco
Stucco & Wood
Fiber Cement
Brick / Stone
Do you have a dog(s):
Yes
No
Do you have any other pets:
Yes
No
If yes, which type(s):
Who referred you to Santa Cruz Insurance:
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