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Maulhardt Insurance Agency 961 N. Rice Ave., Suite 1A., Oxnard, CA 93030 Fax 805 988-8808 Office 805 988-8810 Name _________________________________________________________________ Home Phone ______________________ Work Phone _________________________ Address ______________________________________________________________ Work Address _________________________________________________________ Date of Birth _______________________ Married ________________________ Square Feet _______________ # of stories ___________ # baths ________ Year built ____________ roof type ________________ # car garage ______ Fireplace(s) ____________ Alarm type_____________ Smoke detector _____ Gas shutoff valve_________ House Sprinklers __________ Pool __________ Years at residence_______ Losses past 3 years_______ Current Insurance Company ____________________________________________ Current deductible __________ current premium _______________ |