HOME QUOTE FORM
PLEASE FILL IN ALL INFORMATION SO WE CAN PROVIDE YOU WITH THE BEST PRICE.
PERSONAL INFORMATION
| First: | Middle: | Last: | |||
| Email: | Phone: | Fax: | |||
| Street Address: | |||||
| City: | State: |
Zip: |
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Preferred Contact: |
Please Contact: |
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RESIDENCE INFORMATION
| Home must be located in Texas: | |
| Zip where home is located: | |
| City or County where home is located: | |
| Is Home inside city limits? | |
| Distance to Fire Hydrant: | |
| Distance to Fire Station: | |
| If not in the city limits, list the closest Fire Station: | |
| Central Burgler/Fire alarm that is monitored? | |
| Homeowners Age: | |
| Does anyone in your household smoke? | |
| Dead Bolt Locks, Smoke Detectors, & a 2 1/2lb Fire Extinquisher? |
RESIDENCE REPLACEMENT COST INFORMATION
Needed to determine the approximate cost to rebuild your home.
| Year of construction: | ||
| Style on construction: | ||
| Total Square Feet: | ||
| Basement: | ||
| Foundation: | ||
If Peir and Beam, is foundation blocked-in? |
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| Garage? | Attached is part of the home. Built-in would mean that some of the living area of the home would be over the garage. |
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| Primary Exterior Construction: | ||
| Type Of Roof: | ||
UL Cert: |
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| Full Baths: | ||
| Half Baths: | ||
| Fireplaces: | ||
| Do you have a Wood Deck? | ||
| Do you have a Covered Porch? | ||
| Do you have a Breezeway? | ||
OTHER INSURANCE INFORMATION
| Please tell me about any special insurance needs you may have. For example, Coverage for Jewelry, Furs, Silverware, Guns, Collectibles, etc and any policy needs such as Flood Insurance or Earthquake Insurance: | |
| Please tell me about any Homeowner Claims or Losses you have had in the past 3 years. | |
| If you did not fill in the Replacement Cost Information, please list your current coverages here: | |
| General Comments: |
Thank you for your time in completing this questionnaire.
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