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   Hawkins Insurance &
   Financial Services Group

   2600 South Shore Blvd.,
   Suite 300

   League City, TX 77573

   PHONE: 832-554-7388
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   MOBILE: 832-541-7388
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   FAX: 800-794-9150

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quotes@ryaninsuresme.com

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Your Personal Data
 
Your Name:
Property Address:
City:
Your "County" is?
State: (Must be Texas)
Zip/Postal:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
 
 
Dwelling Information
 
Do you have a TWIA Windstorm Policy Presently? NO YES
 
Year Home Built:
Home Square footage:
 
Is this a New Purchase? NO YES
 
Number of units: 1 family Duplex
 
Type foundation: Slab
Crawlspace over slab
Pier & Post
Other (list in remarks)
 
Type Construction: Frame
Brick/Veneer
Stone
Other (list in remarks)
 
Type Roof: Shingle
Wood Shake
Tar/Gravel
Spanish Tile
Metal Other
 
Number of stories: One 1.5
Two Three
 
Currently Insured? Yes No
Name of Carrier & how long insured?
 
Prior Claims? Yes No
Describe claims in detail:
 
Primary Policyholder's Birthdate:
 
Plumbing type: Copper Galvanized
Mixed (Copper/Galvanized)
 
 

# Bedrooms: # Bathrooms:
 
# Fireplaces: # Chimneys:
 
Coverages:
 
Dwelling Cov. $ Contents $
Deductible $
($250, $500, $1,000, etc.)
 
Comments/Remarks:
 
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