Burnette Insurance Services

	Auto

	Health

	Homeowners

	Condominium

	Renters

	Business

	Boat

	Flood

	Life Insurance

	Motor Club

Your Full Name:
Email Address:
Date of Birth:
Spouse Full Name:
Spouse's Date of Birth:
Street Address:
City:
State:
Zipcode:
County:
Home Phone Number:
Best Time to Reach You:
Do you own / rent your home?
Condominium or Townhouse?
When was your home built?
Total Square Feet:
Style of Home:
Type of Garage:
Is the garage attached or detached from the home?
Is there built-in living space above the garage?	Yes No
Is Your Home a Normal Tract Home or Custom Built?
Number of full baths:
Number of half baths:
Number of fireplaces:
Roof Type (i.e. wood shake, etc.):
Exterior of home (i.e. stucco, etc.):
Is there a burglar alarm?	Yes No
Is there a seperate Jacuzzi / Hot Tub?	Yes No
Is there a Wet Bar?	Yes No
Are there fire sprinklers in the attic?	Yes No
Is this a new home purchase?	Yes No
If Yes, Escrow close date:
Name of current insurance carrier:
Renewal date:
Number of losses in the past three years:
Amount paid if known:
Non-smoker?	Yes No
Are you over the age of 50?	Yes No
Any special riders, increased coverage limits on certain items, i.e. jewelry, fine arts etc.
Are you interested in earthquake, flood and various options available?	Yes No
Do you have an Umbrella liability policy?	Yes No
Who is your auto carrier?

Ron Burnette is licensed to sell insurance products only in the state(s) of California. The material contained in this Web site is applicable only in the state of California. If you do not reside in the state(s) of California or you’re not insuring property located in the state(s) of California, please search for an agent in your area.

California Insurance License Name and Number: 0D73505