BASIC HOMEOWNERS/FIRE/RENTERS INSURANCE QUOTE INFO
Click here if the home your are looking to insurance is not in Texas:

 

What is your first name?  
What is your last name?   
What is your date of birth?     Married: Yes   No:
What is your mailing address?       
City?    

State?     

 

Zip Code?     

   
 
 
  Help is available where

ever you see the   

 

Click here if the home you are looking to insure is at a different address than above:

What is your e-mail address?      
What is a phone # we can reach you at if we have any questions?  
How did you hear about us or  find us?  

Do you have DSL/Cable internet (high-speed)?  
PROPERTY TO BE COVERED INFORMATION
Street Address:  
City   State:  TX
Zip Code:                   What year did you purchase this home?  

Click here if

home is over 30 years old:

 

What county is

 your home located in?

 

Type of Coverage/policy: Homeowners Policy

 
(please check only one selection) Fire Policy:

 
  Renters Policy

Which best describes your property type?

  Condo

 
  Town Home Policy

Is the an end unit or a center unit?
Is there a fire hydrant in the neighborhood?

 Yes No

Is your home in a subdivision?

Yes No

Do you have a concrete driveway?

Yes No

Is your home located on a paved road? Yes No
Is the home within 5 miles of a fire stations?

 Yes No

Is your home on more than 2 acres?

Yes No

Do you have any commercial buildings on your property?

Yes No

If known, what is the name of your fire department?   If unknown, please type in "unknown".
Do you have a smoke alarm?
Do you have a fire alarm. Yes No  Is the fire alarm monitored?
Do you have a burglar alarm. Yes No  Is the burglar alarm monitored?
Do you have a dog of a vicious nature or is prone to bite. Yes No  What is breed of the dog?
Do you have a trampoline? Yes No  
Do you have if you have a pool or hot tub. Yes No  Is your pool/hot tub fenced?
What type of roof does your home have?   Composition shingle is what is most commonly used now.
 What year was your home built?                                                
Click here if your roof has been replaced?

  What year was your roof replaced?    
Click here if your home is not on a concrete foundation.

  Which best describes your homes foundation?
Are you required to have flood insurance?
Have you ever been required to purchase windstorm coverage?
Choose the construction Brick

%  
of your home: Veneer/Wood

%  

(Choose as many as needed but total should equal 100%)

Stucco

% Is this ?
  Log

%  
  Asbestos

%  
  Other

%

Please explain "other":

What is the square footage of your home?

 

How many stories is your home?

How many Bedrooms is your home?

How many full bathrooms?

# of half baths ?

Who occupies this home? Who is the builder of your home?
Click here if you do not have auto insurance with our Agency?  
If you currently have coverage, who do you currently have coverage with?  
When does it expire next?

Do you pay the premium or your mortgage company?  
   
COVERAGE INFO (For help with coverages, please click "?" buttons)
Dwelling coverage:

$$35,000 Minimum - $2,000,000 Maximum
Loss of use coverage: $If unsure, leave blank as this is general 10-20% of the dwelling coverage.
Contents coverage: $ This is optional coverage, if not needed just leave blank.
Liability coverage: $ $25,000 Minimum - $500000 Maximum
Medical payments to others: $ $500 Minimum - $5000 Maximum
Replacement cost dwelling: Yes No
Replacement cost contents: Yes No
Back up of sewers & drains: Yes No
Residence glass coverage: Yes No
     
Other coverages needed:
Your social security #:

What deductibles do you want?
How many deductibles do you currently have on your current policy. If you do not have a policy, please skip?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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