200 E. Sandpointe Ave. Ste. 310
Santa Ana, CA 92707

Phone: (714) 918-0914
Fax: (714) 918-0922

email: info@kleincosta.com

Vacant Buildings

Insurance Agency AGENT
Your Name  
Your Email Address  
Your Phone Number  
California, Nevada or Hawaii License Number
enter “broker” if you already have a broker agreement with us

Name of Insured INSURED
Address of Insured  
Address of Vacant Building  
Area in Square Feet of Building  
Prior Use of Building  
How Long Vacant  
Building Limit  
Building Year Built  
Building Construction  
NOTE: All Fields Must Be Completed