The California Earthquake Authority form is an essential document for individuals seeking earthquake insurance in California. This application gathers crucial information about the applicant and the insured property, ensuring that the coverage is tailored to specific needs. To begin the process, fill out the form by clicking the button below.
The California Earthquake Authority (CEA) form serves as a critical document for individuals seeking earthquake insurance in California. This application form requires applicants to provide essential personal information, including names, contact details, and the physical address of the property to be insured. It also mandates the inclusion of companion policy details, such as the name of the participating insurer and the relevant policy number. Coverage options are clearly outlined, allowing applicants to select limits for dwelling, personal property, and loss of use, among other choices. The form addresses various types of properties, including homes, mobile homes, and condominiums, ensuring that applicants can accurately represent their insurance needs. Specific questions regarding the condition of the property, such as prior earthquake damage and structural reinforcements, must be answered to assess eligibility. Additionally, the form includes sections for premium calculations and payment options, giving applicants flexibility in how they manage their insurance costs. The completion of the form culminates with the applicant's signature, affirming the accuracy of the provided information and allowing the process to move forward.
Revised—Attachment A
Earthquake Insurance Application
Effective Date
Expiration Date
Applicant Information
Applicant
Telephone Numbers
Last Name
First Name
Middle I nitial
Home
Work
Co-Applicant (if applicable)
Street Address of Physical Location of I nsured Property
Mailing Address (if different)
Number and Street Address
Unit
City
State
ZI P Code
County
Country
Companion Policy Information
Participating I nsurer
Companion Policy Number
Dwelling — Coverage A Limit
Expiration Date (must be same as CEA policy)
Type of Policy
Homeowner
Mobilehome / Manufactured Home
Condominium
Renters
Dwelling Fire
Other (explain in remarks)
Homeowner / Dwelling Fire
CondominiumRenters
Rating Territory
Year Built
Number of Stories,
I ncluding Basement
Construction Type
Frame
Other
Number of Chimneys
Square Footage
Foundation Type
Raised
Slab
Roof Type
Composition
Tile
Wood Shake
Property I nspected?
Yes
No
Date
I s there unrepaired prior
earthquake damage to
the dwelling?
I f yes, DO NOT BI ND and explain in Remarks
Dwelling secured to
foundation?
Cripple walls braced with
plywood or equivalent?
Water heater secured to
building frame?
Dwelling — Coverage A
Dwelling Limit
$
Mobile or Manufactured
Is the home reinforced by
an earthquake resistant
bracing system certified by
the California Department
of Housing and Community
Development?
I f yes, attach a copy of the certification
Same as Companion Policy
Deductible
15%
10%
Personal Property — Coverage C
$5,000
$25,000
$50,000
$75,000
$100,000
No deductible for this coverage if Coverage A deductible is met. No coverage if Coverage A deductible is not met
Loss of Use — Coverage D
$1,500
$10,000
$15,000
No deductible for this coverage
Number of Stories in building
Choose any combination of one or more
of the following options
Option One
Building Property — Coverage A
Real Property — $25,000
There is a $3,750 deductible for this coverage
Option Two
There is a $750 deductible for this coverage
«AND »
Option Three
Loss Assessment — Coverage E
$3,750 deductible
Only available if value of property is $135,000 or less
$7,500 deductible
$11,250 deductible
Remarks
Additional Limited Building Code Upgrade
— optional —
I ncrease Limited Building Code Upgrade coverage from $10,000 to a total limit of $20,000
Premium Calculation
Payment Options
Base Premium
Increased Limits Premium
Hazard Reduction Discount
Total Premium
Annual
+
−
=
I nstallments
Homeowner and Mobilehome only
- if qualifications are met
Additional Interests
Send Bill To
Name
Loan Number
Mortgagee
I nsured
Additional I nsured
Address
Loss Payee
2nd Mortgagee
Additional I nsured Address
I am applying for the insurance indicated, and the information on this application is correct
X
Applicant Signature
Producer Name and Address
Application Date and Time
Earthquake Application 05-09
Attachment A – Page 2
CALIFORNIA EARTHQUAKE AUTHORITY
EARTHQUAKE INSURANCE APPLICATION – 05/09 Edition
INSTRUCTIONS
POLICY EFFECTIVE DATE AND EXPIRATION DATE
Provide CEA policy effective date and expiration date. Expiration date MUST be the same as the expiration date of the companion policy.
APPLICANT
Complete all requested information for applicant(s) including: Name(s)
Telephone number(s)
Street address of physical location of insured property
Mailing address (if different from street address of property’s physical location)
COMPANION POLICY INFORMATION
Complete all requested information for companion policy including: Name of Participating Insurer
Policy number of companion policy
Dwelling limit (i.e., Coverage A) of companion policy (if companion policy has dwelling limit) Expiration date of companion policy
Type of companion policy
POLICY TYPE –RATING AND COVERAGE INFORMATION Identify CEA policy type based on the type of companion policy as follows:
•Homeowner (Companion policy must be either a Homeowners (HO-1, 2, 3, 5, or 8), Dwelling Fire (building), Landlord (building), or Mobilehome policy.)
O MOBILEHOME/MANUFACTURED HOME (Written on CEA Homeowner Policy form; however, requires unique rating information.)
Condominium (i.e. Common Interest Development) (Companion policy must be a Condominium Unit Owners (HO-6) policy.)
Renters (Companion policy must be a Renters (HO-4) , Mobilehome (tenant policy), Dwelling Fire (contents only), or Landlord (contents only) policy.)
Complete all information requested under the applicable CEA policy type. Answer all questions and select desired CEA policy limits and coverage options.
PREMIUM CALCULATION
Provide premium calculations.
PAYMENT OPTIONS
Select payment option:
Annual; or
Installments
SEND BILL TO
Select who should receive the bill:
Insured; or
ADDITIONAL INTERESTS
Complete information requested for each additional interest, including:
Type:
OMortgagee;
OAdditional insured; or
OLoss payee
Name and address
Loan number (if applicable)
REMARKS
Include any additional remarks as needed.
SIGNATURE
Secure the applicant’s signature on the application.
Provide the producer’s name and address.
Provide the date and time the application is completed.
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