Name: Deerfield Advisors Insurance Agency
Address: 16225 Park Ten Place, Houston, TX, 77084, US
Telephone: (281) 550-5864

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
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
Original Purchase Price
Original Purchase Date
Pool
Dive Board
Slide
Construction
Dog on Premise
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
Electrical Year Complete or Partial Plumbing Year Complete or Partial 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:
MM slash DD slash YYYY
If no, previous carrier:
Expiration Date of Current Policy:
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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Date	Description of Loss	Amount of Loss	Open (Y/N)	Closed (Y/N)	Repairs Completed (Partial/Full)

Driver Name	Date of Birth	Driver License Number

Type	Year	Make	Model	Vin Number

Violations	Year	Accidents	Year	Claims	Year