Policy Type:  Home Owners Policy

                                         Renters Policy     

Dwelling Type Private Residence Apartment TownHouse

Non Smoker   New Home Monitored Burglar Alarm

Quality Roof Auto Home (currently have auto with Farmers) Age Over 50  

Name: Social Security Number:

Date of Birth:     Drivers Lic. Number

Address:

City: County: BEXAR KENDALL COMAL MEDINA GUADALUPE ATASCOSA KERR GILLESPIE Zip

   If   Rental Policy Requested Indicate the Amount of Contents Coverage Requested:

Contents:

PURCHASE PRICE:

YEAR BUILT: TOTAL SQUARE FOOTAGE:

NUMBER OF STORIES: ONE TWO THREE OTHER

TYPE CONSTRUCTION : BRICK VENEER 50% or Greater STUCCO FRAME BRICK BrickVeneer and Greater Than 51% Hardy Plank Less than 50% Brick Veneer

GARAGE: ATTACHED BUILTIN CARPORT NONE NUMBER 1 CAR 2 CAR 3 CAR 4 CAR

FULL BATHS ONE TWO THREE FOUR HALF BATHS: ONE TWO THREE FOUR None

DECK SQUARE FOOTAGE: PORCH SQ. FOOTAGE:

FIREPLACE: ONE STANDARD TWO STANDARD ONE CUSTOM TWO CUSTOM THREE CUSTOM ROOF: TILE METAL COMPOSITION 30 YEAR COMPOSITION TAR AND GRAVEL OTHER

HEATING SYSTEM: CENTRAL SPACE SOLAR ALARM MONITORED NOT MONITORED

INSIDE CITY LIMITS:  YES    NO

DISTANCE TO FIRE HYDRANT 100ft 200ft 300ft 400ft 500ft More than 500ft

DISTANCE TO FIRE STATION Less than 1mi 2mi 3mi 4mi 5mi More Than 5mi

FIRE PROTECTION City Volunteer None

SMOKER YES NON-SMOKER

INSURED AGESPOUSES AGE

Which of the following if any do you currently have in your home:

Dead Bolt Locks Smoke Detectors 21/2 LB Fire Extinguisher

Select the way you would like your Quote sent back fax mail e-mail

Home Phone:

Work Phone:

Fax Phone:   E-Mail

Comments

Submission of this form is your consent and authorization to check Driver Information and Credit Records to establish eligibility and placement in one of our Best Company's.

Thank you for allowing us to quote your insurance needs.

Dan Miller Agent

This quote is an estimate of the cost of insurance based on the information provided.

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