You can also get a quote by phone. Just contact NBI Insurance Customer Service at (800) 483-4624.

Your Information
	Name	Phone (home)	Phone (work)
	How did you hear about us?
	Select One... Yelllow Pages Word of Mouth Web Search or Link Other
	Occupation	Any losses in the last 3 years?
		Yes No
		If yes, please explain:

Property Address
	Street & Number	City	State
			Select One... California NBI writes CA policies only
	Zip Code

Current Address (if different than property address)
	Street & Number	City	State
			Select One... California NBI writes CA policies only
	Zip Code

 

Property Info
	Is there a business on the premises?	If yes, please explain:
	Yes No
	Do you own any pets or farm animals?	If yes, please explain:
	Yes No
	Nearest Fire Station	Fire Station Name
	Distance from home to fire hydrant	Distance from home to fire station
	(in feet)	(in miles)
	Year Built	Total Square Footage	Foundation
	Roof Type	Age of roof	Dwelling Style
	Select One... Tile Composite Shingles Wood Shingle		Select One... 1 Story 1 1/2 Story 2 Stories Bi-level Split Level
	Dwelling Type	Garage Type	Garage - How Many Cars?
	Select One... Single 1 1/2 Plex Duplex Triplex Four Plex Condo/Townhouse	Select One... Attached Detached None
	Heating & Air Conditioning	Type of Heat
	Select One... Central Heat and Air Heat Only	Select One... Gas Heating Oil Coal Other
	If house is over 30 years old, have there been any updates to:
	Roof	Electrical	Plumbing
	Yes No	Yes No	Yes No
	If yes, date of update	If yes, date of update	If yes, date of update
	Heating
	Yes No
	If yes, date of update
	Exterior Walls (total must equal 100%)
	% Stucco	% Alum/Vinyl	% Brick Veneer
	% Wood	% Masonry Block	% Solid Brick
	% Solid Stone	% Wood Shake
	Interior Walls	Interior Wall Coverings	Flooring
	Select One... Drywall Drywall Textured Sheetrock Plaster	Paint	Carpet
		Vinyl Wallpaper	Hardwood
		Ceramic Tile	Tile
			Marble tile
			Linoleum
	Number of Bedrooms	Number of Full Baths	Number of Half Baths
	Select One... 1 2 3 4 5 6 7 8 9 10	Select One... 1 2 3 4 5 6 7 8 9 10	Select One... 1 2 3 4 5 6 7 8 9 10
	Number of Fireplaces	Kitchen Counters	Kitchen Appliances
	Select One... 1 2 3 4 5 6 7 8 9 10	Select One... Formica Tile Marble	Select One... Standard Premium
	Type of Security	Amenities
	Alarm - Local	Central Vacuum	Skylights
	Alarm - Monitored	Solar Panels	Greenhouse
	Deadbolt	Spiral Staircase	Indoor Barbeque
	Smoke Alarm	Wet Bar	Bay Windows
	Fire Extinguisher	Sauna	Atrium Windows
	Fire Sprinklers	Intercom	Picture Windows
	Gated Community	Jacuzzi Tub (bedroom)	Bow Windows
	Gated Community - Guard Full Time	Swimming Pool or Spa
		If checked, is pool or spa fenced?	Diving Board or Slide?
		Yes No	Yes No
	Home Description	Exterior Features
	Select One... Standard Home Custom Home	Deck
		Breezeway
		Porch and/or Patio - Open
		Porch and/or Patio - Screened
		Detached Structures
		If checked, describe the structures?
	Do you own a trampoline?
	Yes No

Insurance Info
	Current Home Insurance Company	Home Insurance Expiration Date
		Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Year 2009 2008 2007 2006 2005 2004
	Auto insurance with the same company?	Auto Insurance Expiration Date
	Yes No	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Year 2009 2008 2007 2006 2005 2004
	Direct Bill or Mortgagee Bill?	Is this a new purchase? If yes, Escrow closing date
	Select One... Direct Bill Mortgagee Bill Don't Know	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Year 2009 2008 2007 2006 2005 2004
	Do you have an umbrella policy?	Umbrella Expiration Date
	Yes No	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Year 2009 2008 2007 2006 2005 2004