I would like to request a quote for Home Insurance   Your Full Name Date Of Birth -- mm/dd/yy Spouse Full Name Spouse's Date Of Birth -- mm/dd/yy Street Address City State Zip Code County Phone Number To Contact You Best Time To Contact You Morning Lunch Afternoon Evening E-Mail Address Do You Own Your Own Home Or Rent Own Home Renting Other Is This A Condominium Or Townhouse Unit Condominium Townhouse Other Year Your Home Was Built Total Square Feet Of Your Home Style Of Home One Story One & 1/2 Story Two Story Type Of Garage Garage Carport Is Garage Attached or Detached From Home Attached Detached Is There Built-In Living Space Above Garage Yes No Tract Home or Custom Built Tract Home Custom Built Number of Full Baths One Two Three Four Number of Half Baths One Two Three Four Number Of Fireplaces One Two Three Roof Type Wood Shake Asphalt Shingle Metal Copper Slate Tile Other Exterior Type Brick Stucco Wood Metal Siding Vynil Siding Other Burglar Alarm Yes No Separate Jacuzzi/Hot Tub Yes No Wet Bar Yes No Fire Sprinklers In Attic Yes No Is This A New Home Purchase Yes No If New Home, Date Of Closing -- mm/dd/yy Name Of Current Insurance Carrier Renewal Date -- mm/dd/yy Number Of Losses The Past Three Years Amount Paid If Known Smoker Yes No Are You Over The Age Of 50? Yes No Any Special Riders, Increased Coverage Limits On Certain Items, i.e. Jewelry, Fine Arts, Etc. Are You Interested In Earthquake, Flood, And Various Options Available? Yes No Do You Have An Umbrella Liability Policy? Yes No Auto Carrier

The Avirett Agency, Inc. Full Service Insurance 123 North Main    Meridian, Texas  76665 Phone 254.435.2342  Fax 254.435.2003 This Page Last Updated 01/29/2007 ©2006, 2007 The Avirett Insurance Agency, Inc. All Rights Reserved