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Lic # 0D44460

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Authorized broker for Viking Insurance, Infinity, DriveInsurance from Progressive, AIG, and Bristol West.

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Galaxy Insurance Service Inc
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Flood & Home Quote

Galaxy Insurance Service Inc
1001 East Pacific Coast Highway Suite 107
Long Beach, CA 90806
Phone (562) 591-8901, Fax (562) 591-3901
http://www.galaxyinsurance.com/
csr@galaxyinsurance.com
CA Lic #0D44460

APPLICANT INFORMATION
Bold = Required field
First Name
Middle
Last Name
Last Name
Middle
First Name
Physical Address
City
Zip Code
Zip Code
City
Mailing Address
Year Built
What is the Square Foot of the House
How Many Stories

How Many Fire Places

How Many Garage Stalls

Garage Type
DESCRIPTION OF PROPERTY
Occupancy
Construction Type
Roof Type

Year Update

Is it Flat Roof?
Yes
No
Plumbing Type

Year Update

Electrical Type

Year Update

Year Update

Heating Type
Other (Explain?)
SECURITY SYSTEM

Type of Fence

Animal Type

Kind of Animal

Type

Amount Paid

Close or Open

COVERAGE

Building Amount

Limit of Liability
Medical Payment

Personal Property

*For Renter, Condominium & Flood Only.
Deductible Amount
Foundation
Additional Information or Comments:
Effective Date
Type of Insurance
Building Type
*For Flood Skip to Coverage Section
Central Heating & Air Conditioning System?
Yes
No
Smoke Detector
Yes
No
Central Alarm
Yes
No
Dead Bolt
Yes
No
Sprinkler
Yes
No
Any Swimming Pool
Yes
No
Diving Board
Yes
No
Slide
Yes
No
Any Animals
Yes
No
Any Claim Within 36 Months
Yes
No
Email Address
Home Phone
Alternate Phone