Golden Empire Insurance Agency
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Golden Empire
   Golden Empire Insurance Agency
"Old World Values With New World Technology"
  Homeowners Insurance Quote

We would like to provide you with a free, no-obligation homeowners insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Personal Information
City:   State:   Zip:
Day Phone:   Night Phone:
Best Time To Call:   AM   PM
Email Address:
Occupation:   How Long At Current Job:

Current Homeowners Insurance Information
Company Name (not agency):
Policy Expiration Date:   Premium Amount: $
Amount Insured For: $     Policy Type: Primary Secondary
Term: 6 Months   1 Year   Other:

Home Information
How Long At Present Address:     Year Home Was Built:
Sq. Footage (excluding garage
and basement):
sq. ft.         # of Claims In Last 3 Years:

Structure Information
Age of roof: yrs.

# of Full:
# of Half:

Sq. Ft.:
Deck Sq. Ft.:    
Porch Sq. Ft.:    
Screened Patio Sq. Ft.:    
# of Chimneys:    
# of Hearths:    

Additional Features
Heating System
Central Air
Central Vac
Security Alarm
Fire Alarm
Smoke Detector

Scheduled Personal Property
Please indicate additional property that is not listed in boxes 10-14
Amount of Ins.

Amount of Ins.
  1 Jewelry $ 8 Coins $
2 Furs $ 9 Golfer's Equipment $
3 Fine Arts $ 10 $
4 Cameras $ 11 $
5 Musical Instruments $ 12 $
6 Silverware $ 13 $
7 Stamps $ 14 $
Unattended Car Coverage (Stamps/Coins)
Broad Form Pair & Set Coverage
Non-Mobile Organ Coverage
Safe Credit (Identify Property, Safe Class, Etc)
  ACV Loss Settlement
Replacement Cost Loss Settlement
Breakage Coverage (*On Schedule)
Blanket Coverage
Additional Rating Information

Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have additional
information where there was not enough space, please enter them here.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.


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Golden Empire Insurance

Golden Empire Insurance Agency

28720 Roadside Drive, #376
Agoura Hills, CA 91301
Phone: (800) 899-5556   /   (818) 597-7880   Fax: (818) 597-0078

CA License #: 0338632

Important Note: This website provides only a simplified description of coverages and is not a statement of contract. Coverage may not apply in all states. For complete details of coverages, conditions, limits and losses not covered, be sure to read the policy, including all endorsements.

© Copyright 1999-2003 Golden Empire Insurance Agency

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