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(817) 485-8989
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Grapevine
, TX
*
Indicates required field
Type of Home
*
Single Family Home
Duplex
Townhome
Mobile Home
Other
Year of Construction
*
Roof Type
*
Asphalt (comp) Shingle
Wood Shake
Slate
Tar/Gravel
Clay Tile
Wood Shingle
Foundation
*
Bsmt Fully Finished
Bsmt Half Finished
Bsmt Unfinished
Crawlspace
Slab
Pier
Other
Exterior Walls
*
BV
Stucco
Vinyl Siding
Clapboard
Wood Siding
Log
Other
Year Roof Replaced
*
Garage Type
*
Attached - 1 Car
Attached - 2 Car
Attached - 3 Car
Attached Car Port
Detached - 1 Car
Detached - 2 Car
Detached - 3 Car
Detached Car Port
No Garage
Other
Fire Alarm
*
None
Monitored
Unmonitored
Not sure
Age of AC Unit
*
Age of Hot Water Heater
*
Shed Size
*
Builder
*
Living Area Square Footage
*
Primary Heating
*
Gas (Forced Air)
Electric
Hot Water Radiator
Oil/Coal/Karosene
Propane
Stove
Bedrooms
*
1
2
3
4
5
6
7+
Bathrooms
*
1
1.5
2
2.5
3
3.5
4+
Stories
*
One Story
Bi Level
Two Story
Tri Level
Other
Security System
*
None
Monitored
Unmonitored
Unsure
Municipal Location
*
Inside City Limits
Outside City Limits
Not Sure
Number of Fireplaces
*
Electric 100 Amp Circuit Breaker
*
Yes
No
I don't know
Current Insurance Company
*
Years With Prior Carrier
*
Current Premium
*
Renewal Date
*
How do you pay?
*
Mortgage
Pay in full
Monthly
Dwelling Coverage Desired ($)
*
Personal Liability Coverage Desired
*
$100,000
$300,000
$500,000
$1,000,000
Other
Guest Medical Protection
*
$1000
$3000
$5000
Deductible for Clause I
*
500
1000
1%
2%
3%
4%
5%
Deductible Clause II
*
500
1000
1%
2%
3%
4%
5%
Additional Coverage for Jewelry Watches & Furs
*
Scheduled Personal Property
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Swimming Pool
*
None
In-ground
Above-ground
Have you reported any claims or losses to your insurance company within the past 5 years?
*
Yes
No
Do you own an on or off-premises ATV, Dirt Bike, or Snowmobile?
*
Yes
No
In-Home Business with traffic or Daycare?
*
Yes
No
Number of Dogs and Breed(s)
*
Is your home located in a flood plain?
*
Yes
No
Not Sure
How far away is the fire department?
*
More than 5 Miles Away
Less than 5 Miles Away
How far away is the nearest fire hydrant?
*
More than 1000 feet away
Less than 1000 feet away
Purchase Price (if new home)
*
How far away is the fire department
*
Less than 5 miles
More than 5 miles
Select any additional property features that apply.
*
Dead Bolts
Fire Extinguishers
Tramploline
Covered Deck/Patio
Smoke Detectors
Fire Detection
Sprinkler System
Burglar Alarm
Gated community
Manned Security
Retirement Community
Name
*
First
Last
Email
*
Phone Number
*
Additional Comments?
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