| California | |
| If built prior to 1960, choose all that apply: | Electrical, 100% circuit breakers
Yes
No Yes No Copper Plumbing, 50% or More Yes No |
| Number of Stories | |
| Any Dogs? | Yes No |
| Does House Have Full Interior Fire Sprinkler System? | Yes No |
| To the Best of Your Knowledge, Is the House in a Designated Brush Area? | No |
| $ generally referred to as coverage "A" | |
| Yes No |
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