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

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

email: info@kleincosta.com

Vacant Land

Insurance Agency AGENT
INFO
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
INFO
Address of Insured  

Address or Cross Street Location of Vacant Land AND Area of Vacant Land
in Acres or Square Feet

 
#1
Location:
Area:
 
#2
Location:
Area:  
#3
Location:
Area:  
#4
Location:
Area:  
#5
Location:
Area:  
#6
Location:
Area:  
#7
Location:
Area:  
#8
Location:
Area:  
#9
Location:
Area:  

List Additional Insureds and Their Insurable Interest
if none, enter “none”

 
NOTE: All Fields Must Be Completed