/ Orange Insurance LLC
206.774.7867 [ Office ]
877.288.6103 [ Toll Free ]
206.774.2076 [ Fax ]
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Residential Application for Earthquake or DIC

Named Insured

Mailing Address

StreetCity, StateZip Code

Location Address

StreetCity, StateZip Code

Three Product Options: see descriptions below on page 4.

1. Earthquake Only 2. DIC with EQ & Flood 3. DIC with EQ, Flood & Landslide

Flood Zone ______Flood Zone ______

Zones A & V Excluded Zones A & V Excluded

Landslide Supplemental Required

Year Built ______

Home Square Footage ______

Number of Family Units ______

Foundation ______


  • Basement
  • Crawl space with closed concrete perimeter
  • Crawl space with wooden perimeter
  • Post and Pier
  • Slab
  • Stilts

If there is a Basement:

Basement Square Footage Finished ______

Basement Square Footage Un-Finished ______

Is This a Daylight Basement Yes No

Number of Levels ______

(Includes Basement or Garages)

Unit Type ______


  • Single Family Home - Residential
  • Condominium
  • Townhouse - End Unit
  • Townhouse - Center Unit

Construction ______

  • Adobe
  • Log
  • Masonry
  • Metal/Steel
  • Frame
  • Mobile Home
  • Modular Home
  • Pre-fabricated Home
  • Wood Frame
  • Other

Garage Type ______


  • Attached
  • Basement
  • Built In
  • Carport
  • Detached
  • None
  • Subterranean
  • Tuck Under Parking

Garage Size ______

Owner Occupied

Tenant Occupied

On firm, natural ground? YES NO (Explain: ______)

Degree of Slope ______

  • Flat 0°
  • Minimal 1-15°
  • Gentle 16-20°
  • Moderate 21-30°
  • Steep 31-45°
  • Very Steep >45°

Earthquake Retrofitting ______

Loss History or other risk detail ______

Deductible Option: 2% 5% 10% 15% 25%

Limits Requested

Dwelling $ ______(100% Replacement Value)

Other Structures$ ______(100% Replacement Value)

Contents$ ______(100% Replacement Value)

Loss of Use$ ______(40% of Dwelling Max.)

Ordinance or Law:

Check for Coverage A – Coverage for Loss to the Undamaged Portion of the Building.

Specify Limit for Coverage B and/or C:

$ Limit of Insurance for Coverage B (Demolition Cost Coverage)

$ Limit of Insurance for Coverage C (Increased Cost of Construction)

$ Blanket Limit of Insurance for Coverage B and C

Continued on next page…

Coverage cannot be back dated prior to the date we receive written notice to bind. Coverage is subject to 25% minimum earned premium. Your agency is responsible for that 25%, plus the broker fee, if the premium is not collected from the insured. Terms are Net 20 days from invoice date.

Product Options:

  1. Earthquake Only
  2. DIC including Earthquake & Flood
  3. DIC including Earthquake & Flood & Landslide
  1. Earthquake coverage includes Earthquake Shock, meaning physical damage caused by Earth Movement including Landslide, Mudflow, Earth Sinking, Earth Rising or Shifting, only as a direct and immediate result of Earthquake. Includes coverage for Earthquake Sprinkler Leakage (EQSL). Includes coverage for Volcanic Eruption, meaning eruption, explosion or effusion of a volcano.
  1. DIC including Earthquake & Flood includes above Earthquake perils. Coverage includes Flood except in Special Flood Hazard Zones A or V. Coverage includes All Other Perils (AOP) not excluded. Perils excluded include standard fire policy perils (DP1 or Basic Perils) and theft to personal property in the open or not contained in a building. Perils excluded include a Landslide Exclusion Clause limiting coverage for Landslide, Mudslide or Mudflow only as a direct result of Earthquake, Volcanic Action or Flood.
  1. DIC including Earthquake & Flood & Landslide covers the same as above but does not contain a Landslide Exclusion Clause. The root cause of Landslide, Mudslide or Mudflow does not have to be Earthquake, Volcanic Action or Flood.

A Landslide Supplemental Application is required for this product.

DIC excludes Flood in Special Flood Hazard Zones A and V. Ask us about

Excess Flood over NFIP.

The product descriptions are intended only to be a general description of coverage.

Specific coverages, conditions and exclusions are given only in the policy contract


For Official Agency Use:

Agency & Individual Contact: Orange Insurance, LLC c/o Ron Sievers
Phone #: 206.774.7867
Fax #: 206.774.2076
Need by Date: