Home Owners Insurance
 
Primary Insured's Full Name:
Property Address:
Property City:
Property County: Property Zip Code:
Birth Date:
Social Security Number:
 
If Applicable:
Spouse's Full Name:
Birth Date:
Social Security Number:
 
Any Losses/Claims in the last 3 years:
Year Built: Year Renovated:
Square Footage:
Calculated High Value Home:
Construction Type: Roof Type:
Number of Units:
Outside City Limits: Yes No
Fire Hydrant Distance:
Sprinkler System:
Number of Stories:
Garage Type:
Market Value:
Interior Wall Type: Exterior Wall Type:
Basement Percentage:
Number of Baths (Full and Half):
Number of Fireplaces:
Porch/Breezeway: Yes No
Additional Features (Jacuzzi, Wetbar, etc.): Yes No
Kitchen Grade:
 
Non Smoker: Yes No
Auto/Home Discount: Yes No
Home Security Certificate (Deadbolts, etc.): Yes No
Central Burglar/Fire Alarm (Monitored): Yes No
Local Electronic Burglar Alarm (Sound Only): Yes No
Local Fire/Smoke Alarm (Sound Only): Yes No
Hail Damage: Yes No
 
Personal Liability: $300,000.00
Medical Payments: $500.00
Unscheduled Glass: Covered
Texas Amendment Endorsement: $25,000.00
Mold Coverage with Water Coverage: Yes No
Jewelry/Fine Arts/Silverware/Fur Floater: Yes No
Personal Computer:
Business Personal Property:
 
*Quote sheet is subject to change anytime. Go to www.bcad.org to get specifics on property.*
   
Phone:
Email:
Comments:
   
Or, you may fill print the completed form and fax it to 210-568-1619.
Please fax the completed form to 210-568-1619.
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