First Name:
Last Name:
Phone Number:
Fax Number:
E-Mail Address:
Birthdate
Social Security
Married or Single
Employer
Years With Company
Business Type
Job Title
Who Referred You to Our Site?
PROPERTY INFORMATION
Property Address:
Property City:
Property State:
Texas
Property Zip Code:
County:
Responding Fire Dept
(Rating Question):
Any Losses Filed on
Home or Prior Home:
Dwelling Type:
House
Condo
Townhome
Number Of Bedrooms:
Number Of Bathrooms:
Number of Fireplaces:
Garage Description:
No Carport - Garage
1 Car Carport - Attached
2 Car Carport - Attached
1 Car Carport - Detached
2 Car Carport - Detached
1 Car Garage - Attached
2 Car Garage - Attached
3 Car Garage - Attached
1 Car Garage - Detached
2 Car Garage - Detached
3 Car Garage - Detached
Year Built:
Date You Purchased Your
Home:
How Many Stories:
1
2
If Two Stories, Ground
Floor Square Footage:
Total Square Footage of
Your Dwelling:
Construction Type:
Frame
Masonry Veneer
Masonry
Superior
Roof Type:
Tile
Slate
Metal
Woodshake
Composite Material
Roof Updated: yes
no
If Yes, Year Roof was
Updated:
Does The Dwelling Have
A Pool? yesno
If Pool, Is It Fenced? yesno
If Pool, Is There A
Diving Board? yesno
If Pool, Is There A
Slide? yesno
Property Topography:
Flat Land
Next To A Cliff
Terraced (Sloped)
On A Hill Under 15%
On A Hill 16-30%
On A Steep Hill Over 30%
Gentle Hillside
Foundation Type:
Concrete Slab
Poured Perimeter
Built On Pillars-Piers
Rubble Stone
Brick
Masonry
Protection Distance:
Under 1000 ft to hydrant & less than 5 mi to
fire station
Over 1000 ft to hydrant & less than 5 mi to fire
station
Over 5 & up to 10 mi to a fire station
Over 10 mi to a fire station
Is Dwelling in the
Brush? yesno
Is there a Brush Hazard
within (1) mile of Your Dwelling: yes
no
If yes, has the Brush
been cleared by 250 feet from all sides of Your Dwelling? yes no
Smoke Alarm: yesno
Fire Extinguisher: yesno
Deadbolts: yesno
Electrical Updated:
Yes, Recently Updated
No
Circuit Breakers: yes
no
Copper Wiring: yes
no
Heating - Air
Conditioning, How Old?:
Heating - Air
Conditioning, Thermostatically Controlled?: yes no
Energy Source:
Gas
Electrical
Heating - Air
Conditioning, Central? yes
no
Plumbing Updated: yes no
If Yes, Year Plumbing
was Updated:
Copper Plumbing: yes
no
Interior Automatic Fire
Sprinklers:
None
Partial
Full
Theft Alarm:
None
Local
Central
Fire Alarm:
None
Local
Earthquake Zone:
Earthquake
Retrofitted:
Not Required, Home Built After 1975
Yes, Bolted or Retrofitted for EQ
No
Fire District:
Current Insurance
Company:
Expiration Date of
Current Insurance Policy:
Any Dogs on the
Property: yes
no
If Yes, Number & the
Breed of Each Dog:
Any Other Pets-Animals
on the Property: yes
no
If Yes, Number &
Description of Each Pet-Animal:
Losses-Claims in the
last 5 years:
None
One
Two
Three
Four
Five
If Yes, Date, Amount
Paid & Description of Each Loss-Claim
COVERAGE
INFORMATION
Dwelling Amount
(Coverage A):
Other Structures
(Coverage B):
Personal Property
(Coverage C):
Loss of Use (Coverage
D):
Premise Liability
(Coverage E):
$300,000
$100,000
$500,000
Policy Deductible:
100
250
500
750
1000
2500
5000
If EarthQuake Insurance
is Requested, Select Deductible Percentage %:
No Earthquake Coverage
10% Deductible Requested
15% Deductible Requested
20% Deductible Requested
25% Deductible Requested
30% Deductible Requested
Dwelling Replacement
Cost Coverage: yes no
Contents Replacement Cost Coverage: yes no
Questions or Comments
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