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GET QUOTE
Original Insurance Services offers a wide variety of home owner's insurance coverage, by filling in the form below we will be able to provide with competitive quotes!
Home Insurance Quote Form:
   
Name:
   
Address:
           
City: State: Zip Code:
   
Phone: E-mail:
 

Best time to contact you:
   
 
Residence Information:
   
Property Type:
   
Number of Floors:
   
Inside City Limits: Yes No
   
This is a: Primary Residence Secondary Residence
   
Construction Type:
   
Deductible Amount:  
 
Purchase Date Of Property:
   
Purchase Price Of Property:
 
Coverage Information:
 
Personal Liability:  
 
Medical Payments:  
 
 
Protective Devices:
   
Smoke Detectors:
Dead Bolt Locks:
Fire Extinguisher:
Non Smoker:
Central Station Burglar Alarm (rings at a monitoring center):
Central Station Fire Alarm (rings at a monitoring station):
Police Station Direct Alarm (rings at police station):
Fire Station Direct Alarm (rings at fire station):
Local Burglar Alarm (rings on the premises only):
Local Fire Alarm (rings on the premises only):
Automatic Sprinkler - All Areas:
Automatic Sprinkler - Excluding Attic, Bath, Closet:
   
 
Additional Coverage:
Enter Total Dollar Amount of Itemized Coverage for each Category.
Silverware:
   
Camera:
   
Musical Instrument:
   
Personal Furs:
   
Personal Jewelry:
   
Jewelry in Vaults:
   
Guns:
   
Golf Equipment:
 
Earthquake Coverage? (Not Covered unless you select coverage)  
   
Flood Coverage? (Not Covered unless you select coverage)  
 
Please list all claims and amounts paid for the last 3 years:
   
 
Use this area for any special comments:
   
 
Do you currently have homeowners insurance?
   
Who is you current homeowners insurance company?
   
When does your current policy expire?
   

 

1420 West Redondo Beach Blvd # 5
Gardena, Ca. 90247 

Phone: (310) 538-8666 

   Fax: (310) 538-8628

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