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Sober Living Insurance Association

444 W. Badillo St. Covina, CA 91723 Phone: 626-967-1819 Fax: 626-967-1950

Re: Quote for Sober Living Property Insurance please fill in the following information and fax or mail.

Property Owner: ____________________________________________________________ Address: __________________________________________________________________ City: _______________________________________ State:_________ Zip: __________ Name of Mortgage Holder: ___________________________________________________ Mortgage Holder Address: ____________________________________________________ City: __________________________________________ Zip: _______________________ Mortgage Holder Phone: ______________________ Fax: ___________________________ Loan Number: ______________________________________________________________ Year Built: _________________ Square Footage:_____________________ Pool: Yes No Number of Beds: _________________ Number of Stories:__________________ Contact Name: _____________________________ Contact Phone:____________________ E-Mail Address______________________________________________________________ Names of Additional Insured: __________________________________________________

Would you like to be put on Auto Pay? If so please add credit card information. Your credit card will be billed approximately the 1st of each month.

Name on Card: ________________________ Signature: ____________________________ Credit Card Number: _________________________ Exp Date: ______________________

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Sober Living Insurance Association

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