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Homeowners Insurance
Quotation Form
One Simple Form - takes only 2-3 Minutes!


Please fill out this form COMPLETELY!

We need all of this information
to give you an accurate quote.

Your Personal Data:
 
Your Full Name (REQUIRED):
Your Birthdate (REQUIRED):
Property Address (REQUIRED):
City (REQUIRED):
Your "County" is?
State: MUST be Texas!
Zip/Postal (REQUIRED):
E-Mail (REQUIRED):
Home Phone (REQUIRED):
Alternate Phone:
Fax:

 
Dwelling Information
 
Year Home Built:
Home Square footage:
 
Policy Start Date:
(Effective Date Needed)
 
Is this a Purchase?
(Closing on home?)
NO YES
 
Prior Address, City, State, Zip:
(If at property < 6 months)
Number of units:

1 family Duplex

 
Home Type: Standard Home
Mobile/Manufactured
Rental Property
Manufactured Rental
 
Type foundation: Slab Crawlspace/slab
Pier & Beam Other
(list "Other" in remarks)
 
Type Roof: Asphalt Shingle
Wood Shake Tile
Metal Tar/Gravel
Other
Age_ of Roof:
(If New Enter "0")
 
Number of stories: One 1.5
Two Three
 
Exterior Construction:
Frame, Brick/Stone Veneer,
Stucco, etc)
 
Any animals or pets? Yes No
If yes, list type/for dogs, list breed:
 
Smoke Detector, Dead Bolts &
Fire Extiguisher in the house?
Yes No
 
# of feet to nearest
fire hydrant:
# of miles to nearest
fire station:
 
Currently Insured? Yes No
Name of Carrier & how long insured?
 
Prior Claims? Yes No
Describe claims in detail:
 
Rate Your Credit History:
(Many companies use credit to adjust your price.)
Superior Excellent
Good Fair Poor
 
Alarm System: None Local Alarm
Monitored Burglar
Monitored Burglar & Smoke
 
Circuit Breakers or fuses? Breakers Fuses

# Bedrooms: # Bathrooms:
 
# Fireplaces: # Chimneys:
 
Special features
(i.e., deck, air conditioning, alarm systems, pool, etc.)
 
Coverages:
 
Dwelling Cov. $
Contents $
 (If unsure enter Purchase Price) (Standard 60% of total dwelling Cov)
Liability Cov. $ Deductible $
 (Standard = $300,000) ($250, $500, $1,000, 1%, etc.)
   
Comments/Remarks
(describe any scheduled jewelry, in-home business, or other special coverages needed here):
 

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We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy. You also agree to allow our representitive insurance companies to pull consumer reports based on the information given above. (Insurance pulled consumer reports have no effect on your credit scores).

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Texas auto insurance
 
Brooke Insurance & Financial Services
Toll Free#: 877-440-5800 - Toll Free Fax#: 800-853-4036
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