Walker Insurance Services, a leading independent personal insurance & commercial insurance lines agency in Texas.

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TRAVELERS
Southwest Region
"AGENCY OF
THE YEAR"
AWARD WINNER

HARTFORD
National
"TOP PERSONAL
LINES AGENCY"
AWARD WINNER

America First
TOP PRODUCING AGENCY
 

HOMEOWNERS INSURANCE REQUEST FORM


Thanks for completing this 5-Minute Quick Form!
We look forward to providing quotes with the best company, coverage and premium!

If you like, you can also call us to request a quote over the phone.

Concerned about privacy?  We are a secure site and will respect your privacy
and safeguard your personal information.  Check out our Privacy Policy.
Contact Information
First Name:      Last Name: 
Your current address
Street:
City:    County:
State:     Zip:     
How many years have you been at this address? 
Preferred daytime phone number:    Date of Birth: 
Social Security Number:
Note:  Your SS# is not required to receive a quote.  Why we ask:  Many companies
give a discount for good credit.  The SS# helps us to identify and apply the discount
if you qualify for it.  A credit report is not run to identify this discount.
E-Mail Address: 
It is OK to save my email address for the purpose of current and future correspondence*: Yes  No
How did your hear about Walker Insurance?  
 
Risk Address (If different from above address)
Street:
City:    County:
State:     Zip:    
Is this a new purchase?   Yes   No
 
Rating Information
Home year built:    Total sq. feet (not incl. garage):
Inside city limits?     Within 1000' to hydrant? 
Size of lot: 
Construction type:    Dwelling type:
Please describe if "Other" for either of the above questions:
Roof type:    Roof age:    # of shingle layers:
Age of water heater(s):    Location of water heater(s):
How many full bathrooms?:    How many half bathrooms?
How many stories?   Garage size:  How many fireplaces?
Do you have a swimming pool? Yes  No   If yes:
Backyard fenced?    Diving board?    Slide?
Do you have a trampoline? Yes  No
Security system? Yes  No   If yes, is it monitored? Yes  No
What is your usage of this home?
Any claims on a homeowners policy in the last 5 years? Yes  No
If yes, please describe:
Do you have any pets? Yes  No   
If yes, please describe.  If dog(s), please include breed(s):
Please rate your credit: Excellent  Good  Fair  Poor
Have you had a bankruptcy in the last 7 years?  Yes  No
 
Coverage Information on Your Current Policy
(Skip this section and go to next section if this is a new purchase.)
Total Amount on Dwelling: $
Total Amount of Personal Property: $
Personal Liability:   Medical Payments:
Wind/Hail Deductible    All Other Perils Deductible:
Do you have any endorsements on your policy other than standard
endorsements? (Ex. scheduled jewelry) If yes, indicate here:
 
Your current homeowners insurance company:
Is your policy active and in good standing?
Expiration date of your current homeowners policy:
You may experience significant savings on your homeowners policy by purchasing a companion auto policy.  Would you like to look at an auto policy also?  
Who is your current auto insurance company?
 
Information if Home is a New Purchase
Purchase Price:    Approx. loan amount:
What is your closing date?
 
Other insurance products of interest to you:
(No pressure or commitment - we will just email some helpful info to you.)
Commercial   Life   Individual Health   Group Health
 
Comments:

Important:  I understand completing this form in no way obligates me to purchase coverage nor does it obligate Walker Insurance Services to provide coverage, but must be considered only a request for an insurance quote from Walker Insurance Services.

*Concerned about privacy?  We are a secure site and will respect your privacy and safeguard your personal information.
Check out our Privacy Policy.

At Walker Insurance Services, we are proud to offer quotes for the lowest prices, discount premiums and best rates that you are looking for!
We are a leading independent personal lines & commercial lines agency.

Verhagen, Glendenning & Walker, LLP, dba Walker Insurance Services
Verhagen, Glendenning & Walker, LLP, dba VGW, LLP
Copyright 2003-2007