If you're interested in receiving more information about our agency, or if you have questions regarding other insurance products, please be sure to call or e-mail us.

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.

Applicant Information
First Name *
 Last Name *
Previous Address (if less than 3 years)
 Years
City
 State
 		Zip Code
Location of Property
(If different from above. Include County and Zip)
Applicant's Occupation
(State nature of business if Self-Employed)
 Years
(in Current Occupation)
Applicant's Employer Name
 Years
Employer's Address
Marital Status
 Date of Birth
Co-Applicant Information
First Name
 Last Name
Previous Address (if less than 3 years)
 Years
City
 State
 		Zip Code
Location of Property
(If different from above. Include County and Zip)
Applicant's Occupation
(State nature of business if Self-Employed)
 Years
(in Current Occupation)
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

Coverages / Limits of Liability
HO Form
Dwelling
 Other Structures
Personal Property
 Loss of Use
Personal Liability
(Each Occurrence)
 Medical Payments
(Each Person)
DED (Type and Amount)
All Peril
 Wind / Hail
Theft
 Named Hurricane

Endorsements
Replacement Cost Dwelling
 Replacement Cost Contents
Enter Other Endorsements
Premium
Est Total Premium
 Deposit
 Balance

Payment Plan
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

Rating / Underwriting
Frame
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
Structure Type
Dwelling    Apartment    Condo   
Townhouse    Rowhouse    Co-Op   
Usage Type
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
Protection Device Type
Central System
Smoke   
Temp   
Burglar   
Direct System
Smoke   
Temp   
Burglar   
Local System
Smoke   
Temp   
Burglar   
Heat Type
Primary
 Secondary
Renovation Type
Wiring: Part
 Comp
 Year
Plumbing: Part
 Comp
 Year
Heating: Part
 Comp
 Year
Roofing: Part
 Comp
 Year
Exterior Paint: Part
 Comp
 Year
Date Heating System Last Serviced
 Num of Amps (Elec Syst)
Circuit Breakers
Yes   
No   
Fuses
Yes   
No   
Knob & Tube Wiring
Yes   
No   
Aluminum Wiring
Yes   
No   
Housekeeping Condition
 Plumbing System Condition
Known Leaks in Plumbing System
Yes    No   
Foundation
Open    Closed    None   
Dwelling Location
Within City Limits    Within Fire Dist    Within Prot Suburb   
Occupancy
Owner    Tenant    Unoccupied    Vacant   
Fire Extinguisher Visible to Neighbors
Yes   
No   
Deadbolt
Yes   
No   
Oil Storage Tank Location
Indoors
Above Ground, On Masonry Floor   
Above Ground, Not On Masonry Floor   
Outdoors
Above Ground   
Below Ground   
Swimming Pool
Approved Fence    Diving Board    Slide   
Above Ground    In-Ground   
Windstorm Loss Mitigation Features
Bldg Code Grade
 Inspected?
Yes    No   
Tax Code
Rating: Class
 Spec
Occupied Daily?
Yes    No   
No. of Wks Rented
 Wind Class
Roof Material
 Condition of Roof
Basement
 Garage
 Breezeway
Rating Credits
Non-Smoker    Lightning Protection   
Manned Security    Off Premises Theft Excluded   
Sprinkler
Partial   
Full   
Fireplaces (Enter Number)
Chimneys
 Hearths
 Pre-Fab
 Wood Stove Insert
General Information
Explain all "YES" Responses in Remarks (Except questions marked with an asterisk).
Any farming or other business conducted on premises?
(Including day/child care)
Yes    No   
Any residence employees?
(Number and type of full and part time 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?
(List policy numbers)
Yes    No   
Has insurance been transferred within agency?
Yes    No   
Any coverage declined, cancelled or non-renewed during the last 3 years?
(Not applicable in MO)
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?
(Note breed and bite history)
Yes    No   
Is property located within two miles of tidal water?
Yes    No   
Is property situated on more than 5 acres?
(If yes, describe land use)
Yes    No   
Does applicant own any recreational vehicles (Snowmobiles, Dune Buggies, Mini Bikes, ATVs, etc)?
(List year, type, make and model)
Yes    No   
Is building retrofitted for earthquake?
(If applicable)
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?
(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.)
Yes    No   
RENTERS AND CONDOS ONLY:
    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?
(Give estimated completion date and dollar value)
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?
(Give First Party and limit, and Third Party and limit)
Yes    No   
If building is under construction, is the applicant the general contractor?
Yes    No   
Loss History
Any losses, whether or not paid by insurance, at this or at any other location?
(If yes, indicate year and fill out information below)
Date
 Type
 CAT #
 Amount
Description of Loss
Prior Coverage
Prior Carrier
 Prior Policy Number
 Expiration Date
Additional Interest
Int #
 Loan Number
Mortgage    Additional Interest   
Name and Address
Remarks

* Required to submit this form







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