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Home Insurance Quote
Name
Address
City    State    Zip
Home Phone   
Work Phone
Email (required)
Current
Insurance Co.
Current Coverage Amount
Renewal Date
Occupation
Number of yrs employed at current job
Claims in Last 3 Years 0 1 2 3 4+
Square Footage of Living Space
Year Home Was Built
Updates, if any

 
Type Construction
1-Story
1 1/2-Story
2-Story
Split Level
Bi-Level
Frame or Stucco
Masonry Veneer
Masonry
Other

Foundation

Roof
Basement
Crawl Space
Slab
Asphalt Shingle
Wood Shingle
Tile or Slate
Other
Age of Roof
Garage Bathrooms
1-Car
2-Car
3-Car
4-Car
Attached
Detached
Basement
Built-in
Car Port
# of Full
1 2 3 4 5

# of Half
1 2 3 4 5

Other Features
 Central Air Conditioning  Central Vacuum
 Wet Bar  Whirlpool Tub
 Security System

Fireplaces

# of Chimneys
1 2 3 4 5
# of Hearths
1 2 3 4 5

Basement

Finished  Yes No
Sq. Ft.
Deck, Porch, Patio

Deck sq. ft.

Screened Patio sq. ft.

Porch sq. ft.

Enclosed Porch sq. ft.

Miscellaneous 

Scheduled Jewelry Amt.
Satellite/Antenna Value
Computer Value
Antiques Value
In Home Business
Yes
No
Trampoline
Yes

No

Swimming Pool
Yes
No
If swimming pool yes, is it fenced
Yes
No
# of Acres
# of Farm Animals or Pets
Comments
 

 
  


Capps Insurance - Mt. Pleasant
1610 Shadywood Lane
Mt. Pleasant, TX 75455
(903)572-4366
(800)256-1905
Capps Insurance - Clarksville
312 W. Broadway
Clarksville, TX 75426
(903)427-5656
(800)941-3444

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