Fax Homeowners Insurance

1. What is your email?
2. What is your name?
3. What is your address?
4. City, state and zip
5. Mailing address, if different (enter "same" if same as above)
6. Mailing city, state and zip (enter "same" if same as above)
7. County
8. What is your date of birth?
9. What is your SSN?
10. Spouse name
11. Spouse date of birth
12. Spouse SSN
13. Year built
14. Brick
15. Frame
16. Mobile home
17. Total square feet living space
18. Coverage requesting	$$
19. Any claims on this or any other home in the last three years?
20. If new purchase, did prior owner have any claims?
21. Current insurance company
22. Renewal or closing date
23. Is your roof metal, shingle, or wood? (enter one)
24. How old is the roof?
25. Is your heating gas or electric? (enter one)
26. Is your heating central or space heaters? (enter one)
27. How old is your furnace?
28. Do you have a fireplace?
29. Do you have a wood stove?
30. Do you have smoke alarms?
31. Do you have burglar alarms?
32. Has there been any updates on wiring?
33. Has there been any updates on plumbing?
34. Do you have dogs?
35. What kind of dogs
36. Do you have a trampoline?
37. Do you have a swimming pool?
38. Does your pool have a 4 ft lockable fence?
39. Does your pool have a slide?
40. Does your pool have a diving board?
41. How far is the nearest fire station?
42. How far is the nearest fire hydrant?
43. What is the best phone number to contact you at?
44. Is there an alternate number to contact you at?
45. What is your fax number?
46. Would you like for me to take your auto information and quote you auto insurance?
47. How did you hear about us? From the phone book, a friend, the Internet, or other?

Roy Elliott 308 South Main, Highlands, Texas 77562 Phone 281-843-2947 Fax 281-426-3836 Email: MetRoyElliott@aol.com