Talley-Reed Insurance – Alpine, Texas

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(432) 837-3459

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Homeowner, Renter, or Mobile Home Application

With this information we can get started on your quote more quickly. There are four parts:

1. Contact Information
2. Resident Information
3. Dwelling Information
4. Background Information

Step 1 of 4

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1. Contact Information:
Name*
First Last
Address
Street Address Address Line 2 City State ZIP Code
Home Phone*
Work Phone
Cell Phone
Email*
Preferred Contact Method
- Home Phone
- Work Phone
- Cell Phone
- E-mail

2. Resident Information
Insured
Name
First Last
DOB
SS#
Employer and Occupation
Years Employed
Marital Status
- Married
- SIngle
- Separated
- Divorced
- Widowed
Education Level
- High School
- Associate's Degree
- Bachelor's Degree
Spouse
Name
First Last
DOB
SS#
Employer and Occupation
Years Employed
Marital Status
- Married
- SIngle
- Separated
- Divorced
- Widowed
Education Level
- High School
- Associate's Degree
- Bachelor's Degree
Children in Household:
Name DOB SS# (if any)

We need this information for each child. Click the + button to add another child.

3. Home Information
Type of Insurance
- Homeowners
- Tenant Dwelling
- Renters
- Mobile Home
Year Built - if known
Number of Stories
Ground Floor Sq. Footage - if known
2nd Floor Sq. Footage
No. of Rooms
No. of Baths
No. of Fireplaces
Central Air
- Yes
- No
Central Heat
- Yes
- No
Space Heater
- Yes
- No
Construction Type - if known

Stucco, Wood, Brick, Brick Veneer, Etc.
Roof Type

Metal, Compensation, Etc.
Age of Roof (in years)
Year
Make
Model
Length (in feet)
Width (in feet)
Serial Number
Type of Residence
- Primary Residence
- Seasonal Residence
- Tenant
- Vacant
Fireplace?
- Yes
- No
Factory Installed Fireplace?
- Yes
- No
Exterior
- Wood / Masonite
- Vinyl Siding
- Metal

4. General Information
Location to be Insured
Acres
In Mobile Home Park?
- Yes
- No
Inside City Limits?
- Yes
- No
Years Lived There
Garage Size (no. of cars)
- Attached
- Detached
Carport
- None
- Attached
- Detached
Porch Size (sq. ft.)
- Attached
- Detached
Other Buildings:
Type Sq. Footage

Greenhouse, Shed, Workshop, etc. Click the "+" button to add another building.
Updates in House
- Plumbing
- Heating
- Wiring
Year Plumbing Updated
Year Heating Updated
Year Wiring Updated
Animals:
Type (Dog, Horse, etc) Breed (of Dog)

Click the "+" button to add another animal.
Pool?
- Yes
- No
Trampoline?
- Yes
- No
Amount of Insurance Needed
Amount for Building
Amount for Contents
Any Special Insured Items
Any Claims in the Last 5 years?
- Yes
- No
Please Describe the Claim
Amount Paid
Mortgagee
Prior Insurance
Insurer
Expiration Date
MM slash DD slash YYYY
Years with Insurer
To provide you a firm estimate, our Insurance carriers use information from various reports, such as House Hold Summary Report, C.L.U.E. (claims history) and credit, from consumer reporting agencies. These reports periodically could be ordered to renew or update your insurance. You can obtain a copy of your reports for verification or correction within 60 days through the consumer reporting agencies. Talley-Reed Insurance Agency has strong procedures in place to protect your personal information.

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