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Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.
If you have any questions or need help, feel free to contact us at 510-538-8111



Personal Information
First Name
Required
Last Name
Required
Primary Phone Number
Required
E-Mail Address
Required
Date of Birth
Required
/ /
Marital Status
Required
Property Address
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Property Information
Year Built
Optional
Square Feet
Optional
Number of stories
Required
Dwelling Type
Required
Occupancy
Required
If Tenant Occupied, What Is With Your Mailing Address?
Optional
Year Purchased
Optional
Number of Car Garage
Required
Type of Garage
Required
Foundation
Required
Roof Type
Optional
Year Roof Replaced?
Required
Swiming Pool?
Optional

If Yes, Do you have a Slide or Diving Board?
Optional


Do You Have Any Dogs?
Optional

If Yes, What Breed?
Optional
Do You have A Trampoline?
Optional

Solar Panel
Optional

Interior Features
Number of Kitchens
Required
What Grade is The Kitchen(s)
Required
Number of Full Bathrooms
Required
What Grade Are The Full Bathrooms
Required
Number of Half Bath
Required
What Grade Are The Half Bathrooms
Required
Central Air?
Optional
How Many Fireplaces?
Optional
Wood Stove?
Optional
Central Burglar Alarm?
Optional
Central Fire Alarm?
Optional
Interior Fire Sprinklers?
Required
Floor Covering
Please provide with the Percentage of Each. All must equal to 100%.
Hardwood
Optional
Tile
Optional
Laminate
Optional
Carpet
Optional
Lenoleum
Optional
Do You Currently Have Insurance?
Optional
If Yes, Name of The Current Insurance Provider
Optional
Claims/Property Losses in Past 5 Years (Please Explain)
Optional
How Did You Hear About Us?
Optional
If Referred by a Friend or Selected Other, Please list the Name or Explain.
Optional
Additional Comments
Optional
Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

Hayward Insurance - San Leandro Insurance - Oakland Insurance
First Avenue Insurance Services | 24479 Mission Blvd. Hayward, CA 94544 | Ph: 510.538.8111 | Fax: 888.551.1302

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