Mercury Insurance Group

Homeowner Insurance Application
   
Homeowner's Insurance
Welcome to Supple-Merrill & Driscoll's secure online application for Mercury homeowner's insurance.  Here you can apply for a no-obligation homeowner's quote from Mercury and other major companies with the lowest rates.
To obtain a free, no-obligation quote for your home, condo or apartment, fill out the form below and we will contact you. If you prefer to give information over the phone, fill out the name and phone number areas only and we'll give you a call.
   
Insurance Agents and Brokers
550 El Dorado Street
Pasadena, CA 91101
Map
Phone: (626) 795-9921
Fax: (626) 844-2128

This is a secure application using the mod_SSL cryptography protocol.

Name
Date of Birth
Occupation
Address
City   State   Zip
Home Phone   Work Phone
Email

  

Many of the companies we represent require this information prior to quoting.
Social Security Number
Present
Insurance Co.
Present Coverage Amount
Renewal Date
Current Premium
Current Selling Price
Replacement Cost
Occupation
Claims in Last 3 Years 01234+
Do You Own a Dog(s)? Yes, Breed(s):
Square Footage of Living Space
Year Home Was Built

 

Type Construction
1-Story
1 1/2-Story
2-Story
Split Level
Bi-Level		 Frame or Stucco
Masonry Veneer
Masonry

Foundation

Roof

Basement
Crawl Space
Slab		 Asphalt Shingle
Wood Shingle
Tile or Slate
Other
Age of Roof

Exterior

Stucco

Wood

Aluminum

Garage Bathrooms
1-Car
2-Car
3-Car
4-Car		 Attached
Detached
Basement
Built-in
Car Port

# of Full
12345

# of 3/4

12345

# of Half
12345

Year Remodeled

Kitchen
Year  Replumbed or Remodeled
Earthquake Retrofitting
Foundation Bolted
Chimney Braced
Water Heater Strapped
Electrical
Year Upgraded Type of Wiring

Fuses

Circuit Breakers

Amps of Service Panel
Volts 110 /220
Plumbing

Galvanized

Copper

Year Upgraded
Other Features
 Heating

Year Installed

 Air Conditioning

Year Installed

Protective Devices
Smoke Detectors
Fire Extinguisher
Dead Bolts
Fire / Burglar Alarm

 Security System

Fireplaces Basement
# of Chimneys
12345
# of Hearths
12345
Finished Yes No
Size Sq. Ft.
Swimming Pool
Diving Board
Fenced

Above Ground

Below Ground

Replacement Value

Deck, Porch, Patio
Deck sq. ft.
Screened
Patio sq. ft.
Porch sq. ft.
Enclosed Porch sq. ft.
Household Employees
Gardner - Days/Hours per Week/Month
Housekeeper - Days/Hours per Week/Month
About Valuables
Jewelry
Furs
Fine Arts
Silverware
Camera
Coins
China & Crystal
Personal Computer
Musical Instruments
Sports Equipment
Golf
Stamps
Firearms
Other
Miscellaneous
Other Property

Any Other Owned Residences/Rentals?  If Yes, Please List:

Comments

   

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