Rio Grande Insurance

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To get the most accurate quote,
Please fill in all of the fields below. Fields in red are minimum required to give a rough/quick quote estimate.
We handle insurance in California, Arizona, New Mexico and Utah.

Your desired office of service: (please select one before continuing)

Please provide the following information about you and your property to be insured:

Your Name
Property Address
Time You Have Lived at this Address	5+ years 1-5 years Less than 1 year Do Not Live There now (explain in comments below) This will be a new home purchase
City
State	(We only offer insurance in NM, CA, AZ and UT)
Zip code
Is This your Primary Home?	Yes No (If No, please explain below)
Mailing Address	(if different)
Your Age	Date of Birth:
Day Phone	*REQUIRED
Email Address	*REQUIRED (required to return quote!)
Your Marital Status
Your Occupation
Employer
Years at above Employer

Please provide the type(s) of insurance coverage desired (check all that apply, you must select at least one):

Renter's	Homeowner's
Builder Risk	Mobile Home-Owner's
Dwelling Fire (Landlord)	Mobile Home-Renters
Condo/Townhouse	Commercial Property

What is your desired effective date for this coverage?

Are you within the city limits? Yes No

Is there a mortgage on the property ? Yes No

Is there a 2nd or 3rd mortgage, line of credit or co-signer on mortgage of property? Yes No
If yes, please describe in comments below

What year was your property built?

Please indicate the primary construction type of your property:

Garage type:

What is the total heated square footage of your property? (do not include garage)

What is your desired replacement cost coverage for your home's main structure?

How much is your home replacement cost currently insured for, if different from above?

Desired All-Perils Deductible:

Desired Liability Coverage:

Desired Medical Payments Coverage, per person:

Approximate distance to nearest fire station (in miles)

Approximate distance to nearest fire hydrant (in feet)

Please indicate the main type of heating system:
If there is any additional type of heating, please describe in the comments box at the bottom

Please indicate the type of roofing material: If other, describe below
What year was your roof last replaced? (most companies need to see a roof replaced within last 10 years)

Type of foundation:

Number of Stories

Do you have a wood stove or a fireplace? (if both, explain below)

What type of animal(s) do you have on the property?
Is your animal considered dangerous? Yes No

Is this property currently insured in your name? Yes No
If Yes, with which company:
what is your current approximate annual premium: $.00

If No, when was the last date you had insurance on this property:
If this property is not currently insured, YOU MUST EXPLAIN why in the comments box at the bottom

Is there a home based business on the property? Yes No
If Yes, please describe:
How many people visit your business per week:
Do you need more than $250 of business property coverage? Yes No

Have you had any losses or claims in the past five years? Yes No
If Yes, what type (water, theft, etc.):
If Yes, how much did you receive from your insurance: $.00
If Yes, what was the date(s) of loss/claim:

Is this a business property quote ? Yes
If Yes, name of business:
If Yes, type of business:
If Yes, legal structure of business:
If Yes, Federal Tax ID # of business:

ADDITIONAL ENDORSEMENTS

Are you interested to know the costs of:

Replacement Cost Contents (strongly suggested - otherwise your personal property is covered only after depreciation)	Sewer/Water Backup (strongly suggested)
Identity Fraud Coverage (recommended)	Higher Mold/Fungus/Rot Coverage (usually only $5,000 to $10,000 is included)
Scheduled Valuables (describe below)	Special Computer Coverage
Earthquake	Extended Theft Coverage
Increased Umbrella	Inflation Protection (Desribe annual % below)
Flood Policy

DISCOUNTS

Do you have a security system installed? Yes No

Do you qualify for any of the discount items indicated below:

Deadbolts	Fire Alarm System (remotely monitored 24/7)
Bars on Windows	Smoke Detectors
Fire Extinguisher	College Graduate (Bachelor's degree or higher)
I am also submitting an auto quote	Partial Building Sprinklers
Non-Smoker	Full Building Sprinklers
AARP Member (Enter Member # in comments)

COMMENTS AND SPECIAL DESCRIPTIONS:
Please enter and explain additional comments, dates and types of major upgrades (roof, heating, electrical), additional heating/roof/construction types, security features, AARP member number, special desired coverages or high-priced valuables:
Special coverages include: sewer backup, identity theft, extended liability, computer coverage, business-at-home

In order to give you the most accurate quote, we will need your Social Security Number.
We understand that this is sensitive information, and normally receive it on the phone.
If you prefer a faster quote, you may optionally enter it in the box below:
Social Security #

In order to prepare an insurance quote for you, we will need to check specific information about you, including VIN, MVR, CLUE and credit reports, with insurance companies. By submitting this form, you hereby agree that it is allright for Rio Grande Insurance to run this check and provide you with an insurance quote. Credit checks for insurance qualification do not count negatively as an "inquiry" on your credit report.

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Automobile Insurance, Car Insurance, Property Insurance, Homeowner's Insurance, Medical Insurance and Business Insurance are other names by which the above types of insurance are often referenced. We also offer Travel Insurance, Errors and Omissions, Liability and special coverages. Please contact the office in your state for more information.

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