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Blackburn Insurance
836 S. Carrier Parkway
Grand Prairie, TX 75051

972.263.9482

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Fax: 972-262-7508

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Personal Information

First Name

Last Name

Email Address

Street Address Line 1

Address Line 2

City

State

Zip Code

Home Telephone Number

Work Telephone Number

Mobile Telephone Number

Best Time to Call AM PM

Preferred Method of Contact Email Phone

Current Homeowners Information

Company Name

Policy Expiration Date

Policy Type

Premium Amount

Contents Amount Insured For

Liability Coverage Amount

Deductable

Hurricane Deductable

Home Information

Address of Property to be Insured

How Long At This Address?

Year Home Was Built

Square Footage

Occupancy

Number of Occupants

Dwelling Type

New Home Purchase? Yes No

Closing Date

Purchase Price

Structure Information

Updates to electrical? Yes No

If so, what year?

Updates to plumbing? Yes No

If so, what year?

Updates to roof? Yes No

If so, what year?

How many stories?

Construction type

Foundation type

Roof Type?

Roof Slope?

Age of roof?

Second floor sq. footage

Garage

Garage type?

Features

How many bedrooms?

How many bathrooms?

How many fireplaces?

How many porches/decks?

Porch/Deck Sq Feet

Inside City Limits? Yes No

City Water and Sewer? Yes No

On more than 5 acres? Yes No

Pool Information

Is there a pool? Yes No

Is the pool fenced? Yes No

Lockable Fence? Yes No

Diving Board? Yes No

Pool Slide? Yes No

Screened Enclosure? Yes No

Additional Features

Smoke Detectors? Yes No

Trampoline? Yes No

Security System? Yes No

Security System Type

Acreage?

Breed of dogs on property?

Bite history with dogs? Yes No

Any other animals?

Additional Comments

Any additional appropriate comments?

Automobile Information

Current Auto Insurance Information

Insurance Company Name

Premium Amount

Policy Expiration

Term

Are you a homeowner? Yes No

Vehicle Information

Year

Make

Model

VIN

Name of Title Holder

Annual Mileage

Drive to school/work? Yes No

Airbags? Yes No

Car Alarm? Yes No

Driver Name

Liability Limit

Bodily Damage

Property Damage

Single Limit

Other Coverages

Personal Injury Protection/Medical Payments

Uninsured/Underinsured Motorist - Property Damage

Uninsured/Underinsured Motorist - Bodily Injury

Additional Comments?

Please add additional appropriate comments

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