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    On-Line Earthquake
    Insurance Quote Form
    One Simple Form - takes only 2-3 Minutes!


    Your Personal Data:

    Your Name:
    Property Address:
    City:
    State: (Must be Washington)
    Zip/Postal:
    E-Mail (REQUIRED):
    E-Mail (again to verify):
    Phone (Optional):
    Fax (Optional):
    Year Home Built:
    Home Square footage:
    Current H/O Carrier:
    Current H/O Cov. Amt. $
     
    Is Home Retrofit by
    Licensed Contractor?
    Yes No
     
    Quake coverage now?
    (Required Field)
    Yes No
     
    Current Quake Carrier (type none if no coverage):
    (Required Field)
     
    Number of units: 1 family Duplex
    3 Family 4 Family
     
    Occupancy: Owner Occupied Rental
     
    Type Construction: Wood Frame Wood w/stucco
    Brick (NOT ELIGIBLE!)
     
    Type foundation: Slab Pier & Post
    Crawlspace over slab
    Other (list in remarks)
     
    Type Roof: Shingle Wood Shake
    Tar/Gravel Spanish Tile
     
    Number of stories: One 1.5
    Two Three
     
    Slope (On hill?): None Gentle (>20 degr.)
    Steep Stilts/cliff
     
    Comments/Remarks:
     
    Send my quotation via: E-Mail Fax
    Regular Mail
    Call Me by Phone


    Thank you for filling out this form COMPLETELY!

    We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release them from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

    Yes, I Agree. Please Send Me an Earthquake Quote!


    McGregor Insurance, Inc. - PO Box 429 - Ocean Shores, WA 98569 | PHONE: 360-289-2808 | FAX: 360-637-3523
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