Valley Center Insurance Agency, Inc. Homeowners Quote Home | Request a Quote | Our Products | Contact Us | Our Location | Meet our Staff Please complete this form with as much information as you can. Note that your current insurance policy DEC page will have all of the information you will need to complete this form. If our agent requires any additional information we will contact you. Applicant's Name Home Phone Number Cell Phone Number Applicant's Birthdate (mm/dd/yyyy) Social Security Number Marital Status MarriedSingleDivorcedWidowed Mailing Address City Zipcode What year was your home Built? Size of house (in sq. Ft.) How many bedrooms? 12345More than 5 How many bathrooms? 123More than 3 Is this house currently occupied? YesNo Is this your primary residence? YesNo What is your roof type? TileAsphaltCompositionWood ShakeOther How was your house built? Frame ConstructionBrickMasonryResistiveBlock Burglar Alarm? Yes No Neighborhood watch? Yes No Security Guard service? Yes No Does your house have a pool? Yes No Do you own a trampoline? Yes No Plumbing upgrades performed? YesNo If yes, what year? Electrical upgrades performed? YesNo If yes, what year? Roofing upgrades performed? YesNo If yes, what year? Heat/cooling upgrades performed? YesNo If yes, what year?

	Valley Center Insurance Agency, 27525 Valley Center Rd., Suite B.     Valley Center, CA. 92082                         Ca. lic. no. 0E48178               Ph. (760) 749-0622                         Fax. (760) 749-0628