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General Information
Insurance Information
Property Information
Your First Name
Your Last Name
Street Address
Apt or Unit
City
State
ZIP code
County/Parish
Current residence status?
Own
Rent
Years/months at current residence?
Email Address
Home phone number
Daytime phone number
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What is your current insurance company?
What date does your current policy expire/renew?
How long have you been insured with your current insurance company? (no. years)
Will this insurance replace an existing policy?
Yes
No
How much Residence coverage do you want? (in dollars)
How much personal liability coverage do you want?
$300,000
$500,000
Have you reported any claims or losses to your insurance company within the past 3 years?
Yes
No
Are you interested in a multiple-policy discount (for auto and home insurance)?
Yes
No
Would you like a life insurance agent to contact you about mortgage protection insurance?
Yes
No
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Owner First Name
Owner's Last Name
Owner date of birth
Owner's gender
Male
Female
Owner Social Security Number
Co-Owner First Name
Co-Owner Last Name
Co-Owner Date of Birth
How would you (owner) describe your credit rating?
Excellent
Good
Poor
Unsure
Address of the property to be quoted
Address 2 or Apt. Number
City
County or Parish
State
ZIP code
Please select the property type
Single Family Home
Multi Family Home
Apartment
Condominium
Duplex
Townhome
Mobile Home
Other
Do you currently own (or are you in the process of buying) this property?
Yes
No
Do you now reside, or plan on residing at this property within the next 12 months?
Yes
No
Approximate Year Property Built
Approximate livable square footage of residence (excluding basement, if any)
Is this your primary or secondary residence?
Dwelling design
One Story
Bi Level
Two Story
Tri Level
Other
Exterior wall type (60% or more)
Aluminum or Vinyl Siding
Mostly Brick
Mostly Wood Frame
Stucco
Cinder Block
Mostly Stone
Veneer
Log
Other
Number of bedrooms
1
2
3
4
5
6
7+
Number of Bathrooms
1
1.5
2
2.5
3
3.5
4+
Roof Type
Composition Shingle
Tile
Wood Shingle
Concrete
Other
GarageType
Attached-1 Car
Attached-2 Car
Attached-3 Car
Attached Carport
Detached-1 Car
Detached-2 Car
Detached-3 Car
Detached Carport
No Garage
Describe foundation or basement
Slab
Pier + Beam
Central Burglar Alarm
Monitored
Unmonitored
Unsure
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Mark Walton
Insurance Agent
(713) 237-8246
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This listing is intended for informational purposes only and does not constitute an offer to sell or an offer to buy any product. This site is published in the United States for U.S. residents only.
This information and the products and services described here are intended only for individuals residing in a state where the agent is properly licensed.
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