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Safeguarding Your Dreams, Securing Your Home

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Barbara Barendregt

Baxter Insurance Agency

Phone: 209-770-6626
Email: Insurance@BarbaraBarendregt.com

Home Insurance personalized for YOU.

Get your home online quote today by filling out the form ~>

First Name of Primary Insured*

Last name of Primary Insured*

Date of Birth*

Occupation

First Name of Secondary Insured

Last Name of Secondary Insured

Secondary Insured Date of Birth

Secondary Insured Occupation*

Point of Contact Email Address*

Point of Contact Phone*

for us to call and confirm details*

Insured(s) Mailing Adress

Street, City, State, Zip Code

Address of Property to be insured:*

Street, City, State, Zip Code*

Are you in the process of purchasing this property?*

YesNo

If so, what is the name and contact information for your loan officer (if applicable):

If you currently own the property and it is financed, please provide the name, address and loan number of the Mortgage Holder:

Year property was built or approximate age:

Roof type and age:

Foundation type:

Square footage:

To your knowledge, has the electrical or plumbing been updated? If so, what was updated and when:

Do you know if there is a fire hydrant within 1000 feet of the property?

Do you know how far away the nearest manned fire station is?

Have you had any insurance claims/losses on this or any other property within the last 7 years?*

YesNo

If so, what was the nature of the claim/loss and did the insurance company pay the claim?

Additional Notes

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Safeguarding Your Dreams, Securing Your Home

Barbara Barendregt

Home Insurance personalized for YOU.

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