Bosworth & Associates

BOSWORTH & ASSOCIATES
A UNIQUE INSURANCE AGENCY

Homeowners Quote Form

Please Note: If you prefer not to complete this form, you may obtain a quote by faxing your current homeowners declaration page to 903-581-5369. If possible, have your current policy in front of you when filling out this form.

PERSONAL INFORMATION

Name (REQUIRED):
Address:
City:
State:	TEXAS
Zip Code:
E-Mail Address (REQUIRED):
Phone Number
Fax Number (Optional):
Current Insurance Company:
Expiration Date:

Home Location

Physical Address of Home:
City:
County (REQUIRED):
State:	TEXAS
Zip Code:
How Long at Current Address:
Members of Household:
Inside City Limits or Outside:

Rating Data

Total Square Footage of Home:
Year Home was Built:
Number of Stories:
Construction of Home:
Type of Garage:
# Car Garage:
Roof Construction:
Age of Roof:
Date roof was last updated:	If roof is over 10 yrs old
Date wiring was last updated:	If wiring is over 20 yrs old
Fireplace:
Heating:
Central Air Conditioning:
Number of Bedrooms:
Number of Bathrooms:
Distance to Fire Hydrant:
Distance to Fire Station:
Name of Responding Fire Dept:
Alarm:

Value

Estimated Value to TOTALLY Replace Home
ie: the amount of Insurance Needed on Home

Claims

Any claims on Home in past 3 years:
If Yes, Please enter Date of Loss, Amount of Loss and Cause of Loss

Deductible

Please Choose a Deductible:
Any Comments you feel may be necessary in providing you with this quote:

Thank you for completing our online quote form. We will send you a quote within five business days. Please let us know how you would like us to send you the quote:
E-Mail Fax Phone Call

Please note this is only a quote and does not bind coverage in anyway.

Hosted by: