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E-Mail:
cforman@texas
wideinsurance.com

Phone Lines:
1-866-938-4708
1-979-822-4912

Facsimile:
1-877-203-0358

Mailing Address: 3620 E 29th St.
Bryan, TX 77802

Insurance
License #:

1100633

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Builder's Risk
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!


 
Your Name:
Business Name:
Property Address:
City:
State: Must be Texas!
Zip/Postal:
E-Mail (REQUIRED):
E-Mail
(again for accuracy):
Phone:
Fax (optional):
 
 
Dwelling Information
 
Year Building Built:
Building Square footage:
"County" of contruction:
Policy Period: Continuous Reporting
One Year from effective date
 
Type of Policy: One Shot Remodel
One Shot New Construction
 
Occupancy: Single Family Dwelling
1-4 Units, Residential
5-12 Units, Residential
Commercial, list type in description below
 
Occupancy Type:
(describe entities & and number of units, such as "4 unit apartment" or "2 offices and barber shop", etc.)
 
Type foundation: Slab
Crawlspace over slab
Pier & Post
Other (list in remarks)
 
Type finished basement, if any: None Full
25% 50% 75%
 
Type Roof: Shingle Wood Shake
Tar/Gravel Spanish Tile Metal Other
 
Type of Siding Brick   Vinyl
Wood   Aluminum
 
Type of Construction Material Frame  
Jointed Masonry
Non-Combustible  
Masonry Non-Combustible & Fire Resistive
 
Number of stories: One Two
Three 4 or more
 
# of feet to nearest
fire hydrant:
# of miles to nearest
fire station:
 
Currently Insured? Yes No
Name of Carrier & how long insured?
 
Prior Claims? Yes No
Describe claims in detail:
 
Plumbing type: Copper Galvanized
PVC System
Mixed (Copper/Galvanized)
 
Insurance Protection Class, if known (1-8, 9-10-, etc.):
 

 
Coverages:
 
Building Cov. $ Deductible $
($1,000, $5,000, etc.)
 
Other Coverage/Remarks
(describe any extra coverages needed such as business interruption, robbery, computers, etc.):
 
Send my quotation via: E-Mail Fax
Regular Mail
Call Me by Phone

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