Last Name:

First:

Address:

City:

State:

OK TX

Zip:

Telephone:

Email:

D.O.B

S.S.N.

Employer:

Occupation:

Preferred contact method for quote:

Email Telephone

If by Telephone:

Morning Afternoon Evening

Current Insurance Carrier:

Requested Effective Date:

Construction Date:

Construction of Dwelling:

Frame Brick Stone Other

Type of Roof:

Composition Shingle Wood Shingle Metal Other

Age of Roof:

Less than 1 year 2 years 3 years 4 years 5 years 6-10 years 11-15 years Over 15 years

Age of Plumbing:

Less than 1 year 2 years 3 years 4 years 5 years 6-10 years 11-15 years Over 15 years

Age of Wiring:

Less than 1 year 2 years 3 years 4 years 5 years 6-10 years 11-15 years Over 15 years

Stories:

1 2 3 over 3

Foundation:

Slab Pier & Beam Other

Garage:

Attached Detached Carport Other None

None 1 Car 2 Cars 3 Cars 4 or more

Fire Place:

None 1 2 3 4 +

Swimming Pool:

No Yes - Fenced & Gated Yes - Not Fenced or Gated

Fire Hydrant:

within 100 ft. 101 - 500 ft. 501 - 1000 ft. over 1000 ft.

Burglar Alarm:

None Local Monitored

Central Heat:

Yes No

Central Air:

Yes No

Size (sq ft.):

Wood Stove:

No Yes

Smoke Detectors:

No Yes

Fire Extinguishers:

No Yes

Fire Station:

within 1 mile 1 - 5 miles 6 - 10 miles over 10 miles

If outside city limits, nearest volunteer Fire Department:

within 5 miles over 5 miles

Value of House:

Contents:

Personal Liability:

100,000 300,000 500,000 other

Deductible:

$ 250 $ 500 $ 1000 1 % other