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Commercial Earthquake Quote Form

FAX: (503) 244-6881

You can submit up to 1 location using this online form. Just click on the Submit button at the end of the form when you are done. Please fill out the form below as completely as possible in order to avoid any delays in providing your quote.

Multiple location or multiple building risks

For multiple location risks or multiple building risks, please download and complete a DIC Multi Location Application and return to us as an e-mail attachment. Email to jennifer@niagency.com

indicates a required field Contact Information
Your Name:
Your Phone Number:
Email:
Agency Name:
Fax Number:
Named Insured:
Insured's Mailing Address:
City:	State: Zip Code:
Inspection Contact:
Inspection Contact Phone Number:
New Business/Effective Date:
Mortgagee:
Address:
City:	State: Zip Code:
Location of Risks
Address:
City:	State: Zip Code:
Occupancy (IE: Apt, Condo, Office, Retail, Etc):
Number of Buildings:	Number of Stories:
Construction Type:
Additional Construction Type Notes:
Year Built:	Square Footage:
Type of Parking:
Building Value @ 100%:
Contents Value @ 100%:
Business Income/Extra Expense @ 100%:
Deductible:
Additional Coverages
If building is sprinklered, is Earthquake Sprinkler Leakage (EQSL)required?
Is Building Ordinance required?
Comments/Notes:
Math Question: What does five plus four equal? (Enter the numeral, not the text.) The random math question helps stop SPAMbots from sending us junk email.
This is for indication purposes only. No coverage is bound by clicking "submit". A representative of Nielsen Insurance Agency will contact you with any questions.

Commercial Earthquake Quote Form

Multiple location or multiple building risks

Contact Information

Location of Risks

Additional Coverages