Insurance Proposal Request

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

Request a California earthquake insurance quote from Susman Insurance Agency in Los Angeles. Choose your deductible; a licensed agent compares options. About 5 minutes.

  1. First Name (required)
  2. Last Name (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. Street Address (required)
  6. City (required)
  7. State (required)
  8. ZIP Code (required)
  9. Have you had any claims in the last 5 years? (required; choices: Yes / No)
  10. Home year built (required)
  11. Home square footage (required)
  12. Earthquake Insurance Deductible requested (required; choices: 2.5% / 5% / 10% / 15% / 20% / 25%)
  13. Email (required)
  14. Cell Phone (required)
  15. Are you working with one of our Agents? (required; choices: Yes / No)
  16. Agent’s name (required; only when applicable)