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Name

Address

City

State

Oklahoma Only

ZIP Code

E-mail Address

Phone #

Best Time to Call

Send Quote Via

E-mail  Phone

Residents Type

Current Home Insurance

Yes  No

If Yes, Current Carrier

Date of Expiration

Social Security of Applicant
Date of Birth of Applicant
Social Security of Co-Applicant
Date of Birth of Co-Applicant

How did you hear about us

Home Information

How Long At Present Address Year Home Was Built
Sq. Footage
(excluding garage & basement)
# of Claims In Last 3 Years:
sq. ft.
Please List any claims within the past three years

Structure Information
Type Construction Foundation
Roof Type Roof Age  
yrs  
Garage Size Garage Type

Dwelling Information
Deck/Porch/Patio Fireplaces
Deck Sq. Ft. # of Chimneys 
Porch Sq. Ft. # of Hearths
 Screened Patio Sq. Ft  Wood Burning Stove
Bed Rooms Bathrooms Basements
# of Full
# of Half

Sq. Ft.

Additional Features
Heating System Central Air Central Vacuum
Yes Yes
Security Alarm Fire Alarm Smoke Detector
Yes

Underwriting Questions
Swimming pool  Is pool enclosed Trampoline
Inside city limits How many acres  Miles to fire dept. 
Any Animals If yes what kind
(breed of dogs)
Please list any updates on Wiring (circuit breakers), Plumbing,
and list type of heating system if NOT Central Heat/Air
Amount of coverage on Dwelling Deductible

 Personal Property Information

How much personal property coverage is required Burglary Coverage Included
Yes No

List additional information which may help us provide you an accurate quote.
Also list any additional items you would like scheduled with $value.

Information submitted will be held confidential and will be used for quote purposes only.
By pressing Submit you are authorizing us to verify any information including credit scoring,
if applicable, to provide you with the best rates and most accurate quote.
No Coverage will be bound by this form.

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