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,
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,
Waco
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,
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Name:
Address:
City:
State:
Zip:
Home Telephone #:
E-Mail Address:
Best time to reach you?
AM
PM
Own or Rent home?
Own
Rent
Type of policy:
Homeowners
Condo
Renters
Date you want Insurance to begin:
Present insurance company:
Amount of current dwelling coverage:
dwelling coverage:
Personal Property coverage amount:
Personal Property coverage amount:
Personal Liability amount:
Personal Liability amount:
Deductible:
Deductible
Any Losses in the last 3 years?
Yes
No
Is this a
primary or
secondary residence?
Year of Construction:
Construction type:
Select One
Frame
Stucco
Masonry
Veneer/Masonry
Stories:
Select One
1
1 1/2
2
split-level
bi-level
Age of roof:
Roof type:
Select One
asphalt shingle
wood shingle
tile or slate
other
Garage capacity:
Select One
1 car
2 cars
3 cars
4 cars
Type of Garage:
Select One
attached
detached
basement
built-in
carport
# of Full Baths:
# of 1/2 Baths:
(without tub or shower)
Other Features:
Central AC
Central Vacuum
Wet Bar
Security System
Whirlpool
# of Fireplaces
Square footage of living space:
Please list any special features of you home:
Any additional residences? type/location?
Commercial farming for others?
Yes
No
Check all that apply:
Cattle
Horses
Crops
Farm Employees
List any outbuildings or equipment that you would like insured:
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