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Auto & Home Combo Form
Call Us Today At
(281) 550-5864
Auto & Home Combo Form
First Name (Primary)
Last Name
Date of Birth
Occupation
First Name (Secondary/Spouse)
Last Name
Date of Birth
Occupation
Home Phone
Mobile Phone
Work Phone
Email Address
Physical Address
Please indicate your preferred method of communication:
Voice/Phone
Email
Fax
Text
Own or Rent
Own
Rent
Highest Level of Education
Auto Insurance Section
Driver(s) Info
Driver Name
Date of Birth
Driver License Number
Vehicle(s)
Type
Year
Make
Model
Vin Number
Driving History - Any tickets, accidents or claims in last 5 years? (Please list)
Violations
Year
Accidents
Year
Claims
Year
Approximate Paid Out
At fault?
Yes
No
Vehicle Usage
Work
Pleasure
Miles Driven One Way for Work
Current Insurance
Current Insurance Company
Annual Premium
Policy Expiration Date
Coverages Needed
Liability Only
Full Coverage
Limits Needed
Primary Liability
$25 / $50K
$50 / $100K
$100 / $250K
$250 / $500K
CSL $500K
Uninsured/Underinsured Motorist Coverage
$25 / $50K
$50 / $100K
$100 / $250K
$250 / $500K
CSL $500K
PIP
$2,500
$5,000
Medical Payment
$2,500
$5,000
Comprehensive Deductible
$100
$250
$500
$1000
Collision Deductible
$100
$250
$500
$1000
Rental Reimbursement
Total Loss Replacement
GAP / Loan Lease Coverage? (Pays your Creditor in case you total your vehicle within 2 years in some cases)
Yes
No
Coverage Effective Date
Homeowner Insurance Section
Property Type
Single Family Residence
Condo
Townhome
Duplex
Fourplex
Apartment
Property Owner Occupied
Yes
No
Do you anticipate that this property will ever be unoccupied For more than 30 days once the insurance coverage is effective?
Yes
No
Property Tenant Occupied
Yes
No
What is the closing date?
What is your move-in date?
Physical Address ( Street, City, State, Zip)
Property Address (Street, City, State, Zip)
Mailing Address (Street, City, State, Zip)
Please indicate your preferred method of communication
Voice/Phone
Email
Fax
Text
Property
Year Home Built
Home Sq Footage
1 Story or 2 Stories
# of Bedrooms
# of Bathrooms
Age of Roof
Are you purchasing this home?
Yes
No
If yes, what is closing date and loan amount?
Garage
Attached Garage
Detached Garage
Foundation Type
Slab
Pilings
Piers
Crawl Space
Open Crawl Space Enclosed
Basement
Original Purchase Price
Original Purchase Date
Pool
Yes
No
Dive Board
Yes
No
Slide
Yes
No
Construction
Brick Veneer
Masonary
Stucco
Hardi Plank
Dog on Premise
Yes
No
Dog Breed
Any bite history?
Yes
No
If yes, please give details:
Local Alarm
Smoke Detectors
Burglar
Central Station Monitored Alarm
Fire
Burglar
Property Updates
Year Wiring Updated
Year Plumbing Updated
Age of HVAC
Age of Roof
Square Feet:
Number of Stories:
Number of Acres:
Occupancy:
Type of Construction:
Frame
Other:
PPC:
Inside City Limits?
Yes
No
Primary
Yes
No
Seasonal/Secondary
Yes
No
Relative Resident
Yes
No
Current Insurance
Current Insurance Company
Annual Premium
Policy Expiration Date
Current Insurance Deductible
Current Windstorm Deductible
Current All Other Perils Deductibles
Fire Department Within 5 Miles of Residence?
Yes
No
Miles to Fire Department
Do you have a flood policy currently enforced?
Yes
No
Distance to Hydrant:
Responding Fire Dept:
Prior Carrier Information
New Purchase:
Yes
No
If yes, date of purchase:
Date Format: MM slash DD slash YYYY
If no, previous carrier:
Expiration Date of Current Policy:
Date Format: MM slash DD slash YYYY
Non-renewing?
Yes
No
If yes, reason:
Insurance Claims
Any claims in last 5 years?
Yes
No
Claim Type?
Dollar Value $ of Claim
Has Damage Been Fully Repaired
Yes
No
Loss Information
Date
Description of Loss
Amount of Loss
Open (Y/N)
Closed (Y/N)
Repairs Completed (Partial/Full)
First Mortgagee Information
Loan #
Name
Address
City
State
Zip
Second Mortgagee Information
Loan #
Name
Address
City
State
Zip
Filed for bankruptcy in the past three years?
Yes
No
If yes, please give details:
Declined by any other carrier for credit?
Yes
No
How many years at the property requesting a quote for?
If residing at property less than 3 years please give previous property address (Street, City, State, Zip)
Burglar Bars?
Yes
No
If yes, are all burglar bars equipped with a quick release mechanism?
Yes
No
Animals?
Yes
No
If yes, what type:
If Dog, Breed / Mix:
Swimming Pool?
Yes
No
If yes, is pool fenced?
Yes
No
Self locking gate?
Yes
No
Trampoline?
Yes
No
Business Conducted on Premises?
Yes
No
If yes, # of square feet used for business:
Farming?
Yes
No
Home Office/Business?
Yes
No
Day Care?
Yes
No
Number of children:
Customers on premises?
Yes
No
Other:
Signature
*
Name
*
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