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Earthquake Quote Form


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information
First Name
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Last Name
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Gender
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Date of Birth
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Social Security Number
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Marital Status
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Employer
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Occupation
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E-Mail Address
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Primary Phone Number
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Street
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City
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State
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ZIP / Postal Code
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Mailing Address, if different
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Year Built
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Number of Stories Including Basement
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Square Footage of Location
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Construction Type
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Prior earthquake damage
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Current Homeowner Policy Coverage
Do you currently have insurance?
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Current Insurance Provider
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Expiration Date
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Dwelling Information
Mortgagee and Address
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Dwelling Coverage (Coverage A)
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Other Structures (Coverage B)
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How did you hear about us?
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Square Footage
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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Please note that we cannot bind insurance via email, fax, or phone. Any quotes given are subject to underwriting guidelines by the respective insurance carriers. Any reference of coverage used are not intended to express legal opinion as to the nature of coverage, but rather just a brief generalization of coverages. Please read your policy for specific details of coverages.

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ECI Agency, Inc. | 325 Piedmont Rd N | Piedmont, OK 73078 | Ph: (405) 373-2977 M-F 8am-5pm