Insurance Proposal Request

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What this form asks (16 questions, about 5 minutes)

Request a C.L.U.E. claims history report for a property or yourself through Susman Insurance Agency in Los Angeles. Useful when buying a home or shopping for insurance.

  1. Information about personal requesting report (required; choices: Real Estate Agent / Consumer)
  2. Name of person making request (required)
  3. How did you find us? (required; choices: Search engines / Social media / News story / Referral / I am a current client of Susman Insurance)
  4. Name of Referral (required; only when applicable)
  5. Phone (required)
  6. Email (required)
  7. Street Address (required)
  8. City (required)
  9. State (required)
  10. ZIP Code (required)
  11. Have you had any claims in the last 5 years? (required; choices: Yes / No)
  12. Please select the reports you wish to receive (required; choices: Property CLUE report / Flood zone determination / Fire/Homeowners insurance estimate / Earthquake insurance estimate / Flood insurance estimate)
  13. ... (required; choices: I certify that I have a legitimate need for this request)
  14. Type your name here (required)
  15. Are you working with one of our Agents? (required; choices: Yes / No)
  16. Agent’s name (required; only when applicable)