Art Hollingsworth Insurance Services
Art Hollingsworth Insurance Services

Insurance Application
  We would like to provide you with a free, no-obligation insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

All fields below are required (unless otherwise noted) in order to submit this online application.

Agent Information
Agency Contact:  
( not required )
Phone #:  
Fax #:  

Email Address:

How would you like your quote sent:
 By Fax   By Email

Applicant Information
Address of Risk
Street Address:  
State:     Zip:
Mailing Address (if different from Risk Address)
Mailing Street Address:  
Mailing City:  
Mailing State:     Zip:

Risk Characteristics
Year Built Total Square Feet Deductible Coverage A Replacement Cost Value
Structure Type Construction Type Retrofitting (homes older than 1972)
Duplex - Quadplex
Wood Frame (including stucco
       and brick veneer)
Reinforced Masonry/Concrete
Metal or Steel Frame
Unreinforced Masonry (Ineligible)
Mobile or Modular Home
If the dwelling has a crawlspace,
       it has a concrete perimeter or is
       braced with plywood between
The dwelling is bolted to the
Number of Floors (including basement)
1 Story
2 Story
            3 Stories
Greater than 3 Stories (Ineligible)

Ineligible Risks
Ineligible Risks Include: Risks that share a common wall with another property, risks undergoing construction, risks with unrepaired structural or earthquake damage, risks with excessive mold or wood rot, risks with post & pier and/or stilt foundation, or risks listed on the historic registry.

Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have
additional information where there was not enough fields above, please enter them here.

Please click on the "Submit Application" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.