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Scroll down the page to the Homeowners Insurance Form for you quote. Please include as much information as possible so we can give you an accurate quote that can compare against your current insurance premium.

Primarily Insured Home Owner
Full Name (Required)
Date of Birth
Sex
Mn Day Year
Home Address
City / State (Required)
Zip Code
Phone
Email (Required)

Spouse Information
Name
Date of Birth
Sex
Mn Day Year
Used Tobacco Products In The Last 12 Months?

Current Coverage Information
Current Carrier
Rental/Closing Date?
Flood Insurance
Mn Day Year
Alarm?
Who Monitors?
Any Home / Renter's Insurance Claim in last 3 years?

Property Information
Type of Construction
Other Type of Construction?
Number of Stories?
Year Built
How Many Square Feet?
Number of Fireplaces?
Number of Bathrooms?
Roof Type?
Roof Age?
Do You Have A Porch?
Do You Have A Breezeway?
Do You Have A Deck
Purchase Price?
Loan Amount Remaining?
  
 
Additional Comments:
* Required Fields

 


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Selected Benefits, Inc
Steven Wendlandt - Licensed Agent
3000 Weslayan, Suite 273 | Houston Texas 77027
2633 McKinney, Suite 130-156 | Dallas Texas 75204
3616 Far West Blvd, Suite 117-125 | Austin Texas 78731
Houston Metro: (713) 621-1440 (713) 621-1440 | Toll Free Phone: (866) 270-6209 (866) 270-6209 | Toll Free Fax (877) 718-8056
info@selectedbenefits.com

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