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Personal Information

First Name*

Last Name*

Date of Birth*

Marital Status Single Married

Spouse First Name

Spouse Last Name

Spouse Date of Birth

Phone Number*

Email Address*

Street Address*

City*

State TX only

Zip Code*

Is this a new purachase? Yes No

Previous Street Address

Previous City

Previous State

Previous Zip Code

Property Details

Year Built

Square Feet

Roof Age*

Stories --Please select-- 1 2 3+

Foundation --Please select-- Slab Pier and Beam Basement Other

Exterior Construction --Please select-- Brick Siding Stucco Other

Garage Type --Please select-- None 1 Car Attached 2 Car Attached 3 Car Attached 4 Car Attached 1 Car Dettached 2 Car Dettached 3 Car Dettached 4 Car Dettached Other

Bathrooms --Please select-- 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6+

Underwriting

Do you own any dogs? Yes No

Dog Breed

Any bite history? Yes No

 Any prior claims? Yes No

Claim Description

Any business conducted at this location? Yes No

Business Description

Requested Coverage

Start Date

Dwelling Value

Personal Property Value

Liability Limit 50,000 100,000 300,000 500,000 1 Million Umbrella

Medical Payments 500 1,000 5,000 10,000

Deductible $500 $1000 1% 2%

Flood Insurance Yes No

Discounts

Bundle Home & Auto Yes No

Current Insurance Yes No

Current Company

Current Liability Limit --Please select-- 50,000 100,000 300,000 500,000 1 Million Umbrella

Current Insurance Length --Please select-- 0-5 Months 6-12 Months 1-3 Years 3-5 Years 5+ Years

Current Policy Expiration

Do any household members smoke? Yes No

 Fire Extinguisher Yes No

Security System --Please select-- None Monitored Unmonitored

Fire Alarm --Please select-- None Smoke Detector Monitored

Smart Home --None-- Smart Thermostat Smart Doorbell Camera Water Leak Detection/Shut-off Gas Leak Detection/Shut-off Automatic Fire Sprinklers

Additional Comments

Disclaimer: By submitting this quote, you authorize Neighbor’s Choice Insurance Agency and the companies they represent to run consumer reports including, but not limited to MVR, C.L.U.E., UDD and Credit.

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