Gregg Stapp Insurance Services • 810 East Commonwealth • Fullerton, CA 92831  • (714) 680-6504 • stapp6@aol.com

 810 East Commonwealth • Fullerton, CA 92831
(714) 680-6504  •  Fax: (714) 680-6509  •  stapp6@aol.com
Mon-Fri 9am-5pm

Customer Satisfaction Is Our #1 Priority

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Gregg Stapp Insurance Services 
810 East Commonwealth
Fullerton, CA 92831
 
Located in the Von Esch Law Building on the 2nd Floor

Phone: (714) 680-6504
Fax: (714) 680-6509
Email stapp6@aol.com

Gregg Stapp Insurance Services
CA License #0806917

If you would like an Homeowner Insurance Quote, please fill out the form below and click "Submit." We will get back to you as soon as possible regarding your quote.

First Name
Last Name
Previous Address (if less than 3 years)
Years
City
State
Zip Code
Location of Property
Applicant's Occupation
Years
Applicant's Employer Name
Years
Employer's Address
Marital Status
Date of Birth
First Name
Last Name
Previous Address (if less than 3 years)
Years
City
State
Zip Code
Location of Property
Applicant's Occupation
Years
Applicant's Employer Name
Years
Employer's Address
Marital Status
Date of Birth
How long have you known the applicant?
Date Agent last inspected property
HO Form
Dwelling
Other Structures
Personal Property
Loss of Use
Personal Liability
Medical Payments
All Peril
Wind / Hail
Theft
Named Hurricane
Replacement Cost Dwelling
Replacement Cost Contents
Enter Other Endorsements
Est Total Premium
Deposit
Balance
Account Number
Billing
Direct Bill
Agency Bill
If Direct Bill
Bill Applicant
Bill Mortgagee
Other
If Other, please specify
If Applicant Bill
Full Pay
Other
If Other, please specify
Mail Policy To
Agent
Applicant
Other
If Other, please specify
Masonry
Masonry Veneer
Mfg Home
Vinyl Siding
Aluminum Siding
Fire Res
Year Built
Number of Rooms
Market Value
Square Footage
Number of Apts
Replacement Cost
Dwelling
Apartment
Condo
Townhouse
Rowhouse
Co-Op
Primary
Secondary
Seasonal
Farm
COC
Comp Date
No. of Families
No. of Household Res
Purchase Date & Price
Number of Fire Divs
Units in Fire Div
Terr Code
Prem Group
Protect Class
Distance from Hydrant (ft)
Distance from Fire Station (mi)
Fire / EC Rate
Fire District / Code Number
Smoke
Temp
Burglar
Smoke
Temp
Burglar
Smoke
Temp
Burglar
Primary
Secondary
Part
Comp
Year
Part
Comp
Year
Part
Comp
Year
Part
Comp
Year
Part
Comp
Year
Date Heating System Last Serviced
Num of Amps (Elec Syst)
Yes
No
Yes
No
Yes
No
Yes
No
Housekeeping Condition
Plumbing System Condition
Yes
No
Open
Closed
None
Within City Limits
Within Fire Dist
Within Prot Suburb
Owner
Tenant
Unoccupied
Vacant
Fire Extinguisher Visible to Neighbors
Yes
No
Deadbolt
Yes
No
Indoors
Above Ground, On Masonry Floor
Above Ground, Not On Masonry Floor
Outdoors
Above Ground
Below Ground
Approved Fence
Diving Board
Slide
Above Ground
In-Ground
Windstorm Loss Mitigation Features
Bldg Code Grade
Inspected?
Yes
No
Tax Code
Class
Spec
Occupied Daily?
Yes
No
No. of Wks Rented
Wind Class
Roof Material
Condition of Roof
Basement
Garage
Breezeway
Non-Smoker
Lightning Protection
Manned Security
Off Premises Theft Excluded
Sprinkler
Partial
Full
Chimneys
Hearths
Pre-Fab
Wood Stove Insert
Any farming or other business conducted on premises?
Yes
No
Any residence employees?
Yes
No
Any flooding, brush, forest fire hazard, landslide, etc?
Yes
No
Any other residence owned, occupied or rented?
Yes
No
Any other insurance with this company?
Yes
No
Has insurance been transferred within agency?
Yes
No
Any coverage declined, cancelled or non-renewed during the last 3 years?
Yes
No
Has applicant had a foreclosure, repossession, bankruptcy, judgment, or lien during the past 5 years?
Yes
No
Are there any animals or exotic pets kept on premises?
Yes
No
Is property located within two miles of tidal water?
Yes
No
Is property situated on more than 5 acres?
Yes
No
Does applicant own any recreational vehicles (Snowmobiles, Dune Buggies, Mini Bikes, ATVs, etc)?
Yes
No
Is building retrofitted for earthquake?
Yes
No
During the last 5 years (10 years in Rhode Island) has any applicant been convicted or any degree of the crime of arson?
Yes
No
Is there a manager on the premises?*
Yes
No
Is there a security attendant?*
Yes
No
Is the building entrance locked?*
Yes
No
Any uncorrected fire or building code violations?
Yes
No
Is building undergoing renovation or reconstruction?
Yes
No
Is house for sale?
Yes
No
Is property within 300 ft of a commercial or non-residential property?
Yes
No
Is there a trampoline on the premises?
Yes
No
Was the structure originally built for other than a residence and then converted?
Yes
No
Any lead paint hazard?
Yes
No
If a fuel oil tank is on premises, has other insurance been obtained for the tank?
Yes
No
If building is under construction, is the applicant the general contractor?
Yes
No
Any losses, whether or not paid by insurance, at this or at any other location?
unlabeled choice 1
Date
Type
CAT #
Amount
Description of Loss
Prior Carrier
Prior Policy Number
Expiration Date
Int #
Loan Number
Item
Mortgage
Additional Interest
Name and Address
Remarks
Bold = Required field
Applicant Information
(If different from above. Include County and Zip)
(State nature of business if Self-Employed)
(in Current Occupation)
Co-Applicant Information
(If different from above. Include County and Zip)
(State nature of business if Self-Employed)
(in Current Occupation)

Coverages / Limits of Liability
(Each Occurrence)
(Each Person)
DED (Type and Amount)

Endorsements
Premium

Payment Plan

Rating / Underwriting
Frame
Structure Type
Usage Type
Protection Device Type
Central System
Direct System
Local System
Heat Type
Renovation Type
Wiring:
Plumbing:
Heating:
Roofing:
Exterior Paint:
Circuit Breakers
Fuses
Knob & Tube Wiring
Aluminum Wiring
Known Leaks in Plumbing System
Foundation
Dwelling Location
Occupancy
Oil Storage Tank Location
Swimming Pool
Rating:
Rating Credits
Fireplaces (Enter Number)
General Information
Explain all "YES" Responses in Remarks (Except questions marked with an asterisk).
(Including day/child care)
(Number and type of full and part time employees)
(List policy numbers)
(Not applicable in MO)
(Note breed and bite history)
(If yes, describe land use)
(List year, type, make and model)
(If applicable)
(In RI, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment.)
RENTERS AND CONDOS ONLY:
(Give estimated completion date and dollar value)
(Give First Party and limit, and Third Party and limit)
Loss History
(If yes, indicate year and fill out information below)
Prior Coverage
Additional Interest

Homeowner Insurance Form

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