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444 W. Badillo Street, Covina, CA 91723 Phone (626) 9671819, (800) 4949844 Fax (626) 9671950 Re: Quote for Sober Living Liability Insurance please fill in the following information and mail or fax. Property owners: ______________________________________________________ Name of House: ______________________________________________________ Address of house:______________________________________________________ City: _______________________________ Zip Code: _________________ Phone Number: ______________________ Fax Number: ______________ Year Built: __________Square Footage: ____________ Pool: Yes or No

Number of Beds: _______________Number of Stories: _________ Member of which County Coalition? [mandatory]_____________________________ Billing Name: _________________________________________________________ Billing Address: _______________________________________________________ City: _____________________________________ Zip: _____________________ Contact Name: ___________________________Contact Phone #_________________ Cell Phone #____________________

th If you would like to pay by credit card, your card will be billed on the 15 of each month

Exact Name on Card:_______________________________ Signature:________________________ Credit Card # ___________________________________________ Exp. Date_________________ This is an application for Insurance Quote only


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