ALLIED INSURANCE AGENCY, INC.

12750 Merit Drive, Suite 730, LB 70

Dallas,  TX 75251

Direct:  214-269-1560

Fax:  214-691-1622

www.alliedins.com

Note:  Some carriers may also ask for your birthdate, Social Security number, occupation and/or employer.  However, because we take very seriously the threat of internet fraud and identity theft, we will never ask you to submit such information through an on-line application.  If a carrier needs more information, we will call you directly at the phone number you provide to obtain it.

TELL US ABOUT YOUR HOME

BASIC INFORMATION

TYPE OF HOME

NUMBER OF FLOORS

SQUARE FEET

ROOFING

EXTERIOR

FOUNDATION

GARAGE

"Bricks and mortar make a house, but the laughter of children make a home."

IRISH PROVERB

USE

VALUE/ESTIMATED REPLACEMENT COST OF THE HOME

ESTIMATED AMOUNT TO REPLACE PERSONAL PROPERTY (YOUR STUFF IN THE HOUSE)

AMOUNT OF LIABILITY INSURANCE DESIRED (IN INCREMENTS OF $100,000)

DEDUCTIBLE

SWIMMING POOL?

TRAMPOLINE?

WITHIN 1000 FEET OF A FIRE HYDRANT?

WITHIN 2 MILES OF A FIRE STATION?

BURGLAR ALARM?

FIRE ALARM?

HOW MUCH COVERAGE DO YOU NEED?

YEAR BUILT

DOES THE VALUE OF YOUR GEMS, JEWELRY, WATCHES, AND FURS EXCEED $500?

DOES THE VALUE OF YOUR FINE ARTS, PAINTINGS, AND OTHER COLLECTIBLES EXCEED $500?

Single-FamilyDuplexFourplexTownhouseCondominiumApartmentMobile HomeOtherI don't know

One storyOne and a half storiesTwo storyTwo and a half storiesThree storyMore than three storiesI don't know

Less than 1,000 1,001-1,500 1,501-2,0002,001-2,5002,501-3,0003,001-3,5003,501-4,0004,001-4,5004,501-5,0005,001-5,5005,501-6,0006,001-6,5006,501-7,0007,001-7,5007,501-8,0008,001-8,5008,501-9,0009,001-9,5009,501-10,000More than 10,000I don't know

Architectural ShinglesAsphalt ShinglesClay TileConcrete TileCorrugated SteelFiber ShinglesMineral Fiber ShinglesMission TileRock RoofRoll RoofingSlateTar/Gravel/Built UpTinWoodWood ShakeI don't know

Brick VeneerCementConcreteLogSiding, AluminumStoneStuccoWoodOtherI don't know

Concrete SlabPier and BeamBasement, UnfinishedBasement, Partially FinishedBasement, FinishedOther type of basementOtherI don't know

Attached - 1 carAttached - 2 carAttached - 3 carDetached - 1 carDetached - 2 carDetached - 3 carCarport - 1 carCarport - 2 carCarport - 3 carNoneOtherI don't know

Primary ResidenceSecondary ResidenceGuest HouseRentalOther

$500$1000$2000$2500$5000More than $5000

YESNO

YESNO

YESNO

YESNO

YESNO

YESNO

200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957Before 1957

YESNO

YESNO