Homeowner's Quote

Thank you for giving us the opportunity to earn your business.
Please fill out as much of the form as you can.
We are independent so we will get quotes from all multiple carriers for you.
We will also call you upon receipt of this quote request.

* Required
* Applicant  
Date of birth (mm/dd/yyyy)
Social Security No. (optional)
Occupation
Co-applicant
Date of birth (mm/dd/yyyy)
Social Security No. (optional)
Occupation
Address
City
Zip
* Home Phone  
Cell Phone
* E-mail  
How did you hear about us?
Living in the house full time? Yes  No
Home
Effective date of coverage Year Built
Square Footage Number of Stories
Construction Roof Type
Roof Age Number of Bedrooms
Fireplace Yes  No Fire Extinguisher Yes  No

Smoke Detector

 Yes  No

Monitored Alarm

 Yes  No
Deadbolt Yes  No Formal Dining Room Yes  No
Circuit Breakers Yes  No Fuse Box Yes  No
Electric Yes  No Gas Yes  No
Any Animals Yes  No Are animals vicious Yes  No
Pool Yes  No Diving Board Yes  No
Trampoline Yes  No Indoor Sprinklers Yes  No
Distance to Fire Hydrant Distance to Fire Station
Current Insurance Co. Name of Mortgage Co.
Street City
Zip Loan No.
Past claims for last three years Current Carrier
Coverage
Liability $300,000  $500,000  Other
Medical Benefit $1,000  $2,000 $3,000
Home Purchase Price Loan Value
Glass Coverage Yes  No Water Coverage Yes  No
Jewelry $500  $1,000  $2,500   $5,000

Please provide any updates to home if over 20 years old. (These are very important.)
Wiring Type Plumbing
Heating   Water Heater Type   A/C Type
Business in Home Yes  No  If yes, what type:

Comments

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Safe Harbor Benefits, Inc.
1321 W. Randol Mill Rd., Ste. 100 • Arlington, TX 76012
817-226-3372 • Fax 817-277-4577

Map of 1321 W Randol Mill Rd, Arlington, TX 76012-3159

Securities offered through InterSecurities, Inc.

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