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LOCATIONS
FAQ
Todays Date
02/23/2012
Date to start Coverage
Applicants Name
Date of Birth
SS#
Email address
Home Phone
Work Phone
Cell Phone
Property Address
ZipCode
State
choose
TX
Same as Mailing Address
Yes
No
Mailing Address
ZipCode
State
choose
TX
Mortgage / Bank Info
Market Value
Square Footage
Year Home was built
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
Type of foundation
choose
Pier & Beam
Slab
How many rooms
How old is the roof
How many layers
choose
1
2
3
4
5
Is the home
Brick
Frame
Stucco
Brick-Veneer
Wood
Other
If other please specify
Value of your contents
Do you want mold coverage for an additional cost
Yes
No
Do you need any additional coverage for registered guns, jewlery, bullion, furs and etc.
Yes
No
Do you have a pool
Yes
No
If Yes what type
ingound
above
Hot tub?
Yes
No
Diving boards or slides
Yes
No
Is the pool fenced
Yes
No
Do you have a trampoline
Yes
No
Distance from fire department?
Premises occupied daily?
Yes
No
House keeping condition
Is this a primary residence?
Yes
No
Vacant or vacation home?
vacant
vacation
Do you run a business from your home?
Yes
No
Type of air conditioning
none
window
packaged
split
central air conditioning
Type of Heating
none
geotermal
boiler
steam radiant
hydronic
radiant heat
forced air heating and oooling
Any wood stoves?
Yes
No
Any security system
Yes
No
If so What type
local
monitored
Do you have a fire extinguisher?
Yes
No
Dead bolts?
Yes
No
Smoke Detectors?
Yes
No
Do you have insurance now?
Yes
No
Any claims in the last 5 years
Yes
No
Please, verify all information before submitting.
