Choose an insurance type from the choices below.


Auto Insurance


Personal Information


Name Email Address
Address Day Phone
City Night Phone
State  Zip  Best Time to Call   AM   PM
Preferred Contact Method Email   Phone


Current Auto Insurance Information


Company Name Policy Expiration
Premium Amount Term
Are You A Homeowner? Y  N Insurance
Carrier


Vehicle Information

(include all cars you or your family members own or lease)
Car #1
Year
Make
Model
Body Type
Vehicle ID# (VIN)
Name of Title Holder
Annual Milage
Drive to school/work?
# of miles
(one way)
  Airbags  
Car Alarm
Y N
Y  N
Y  N
If vehicle is kept at an address other than that listed above, please indicate below
Location City:   State:   Zip:
Driver Name


Car #2 (enter info)

Car #3 (enter info)

Car #4 (enter info)


Liability Limit

for ALL Cars
Choose either   Bodily Injury   and   Property Damage
or   Single Limit
Bodily Injury
        
Property Damage
Single Limit

The minimum auto liability coverage amount required by the states of Texas and Arkansas is $30,000 for each injured person, up to a total of $60,000 per accident, and $25,000 for property damage.


Other Coverages


Personal Injury Protection/Medical Payments
Uninsured/Underinsured Motorist - Bodily Injury
Uninsured/Underinsured Motorist - Property Damage

Texas and Arkansas insurers must offer you $2,500 in Personal Injury Protection, but you can buy more. Texas and Arkansas require insurance applicants to reject PIP coverage in writing if they don't want it.


Deductibles and Misc.


Car#
Comprehensive Deductible
Collision Deductible
Towing
Rental Reimbursement
1
Yes
Yes
2
Yes
Yes
3
Yes
Yes
4
Yes
Yes



Driver Information (include all licensed drivers in your household)

Driver #1

Driver's Name
Drivers License Information
DL#: State:
Yr's Licensed:
Relation
Date of Birth
Sex
Marital Status
Courses Completed Last 3 yrs
M
F
Married Single
Drivers Ed: 
Defensive Driving;
Drug & Alcohol Awareness: 
Driver's SSN


Driver #2 (enter info)

Driver #3 (enter info)

Driver #4 (enter info)


Driver History


List ANY convictions for ANY driver convicted of moving traffic violations in the past 3 years
Driver
Date
Type of Conviction
Speed Over Limit
mph
mph
mph
mph


List ANY driver who has had license suspensions, revocations or DUI convictions below
Driver
License Suspended or Revoked
DUI Conviction For:
Suspended   Revoked  
Alcohol   Drugs  
Suspended   Revoked  
Alcohol   Drugs  


List ANY driver involved in accidents, regardless of fault, in the past 5 years
Driver
Date
Description
Cost
Injuries
At Fault
$
Yes
Yes
$
Yes
Yes
$
Yes
Yes
$
Yes
Yes



Additional Comments



Please give any additional comments you feel appropriate for this quotation.


Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.



Home Insurance

Name Email Address
Address Day Phone
City Night Phone
State

Zip

Best Time to Call   AM   PM
Date of Birth Preferred
Contact Method
Email   Phone
Occupation Time at
Current Job
SSN



Spouse or Additional Insured


Name
Occupation
Date of Birth
SSN



Current Homeowners Insurance Information


Company Name (not agency):
Policy Expiration Date:   Premium Amount: $
Dwelling Amount Insured For: $     Policy Type: Primary Secondary
Contents Amount Insured For: $
Liability Coverage Limit: $
Deductible: Clause 1     Clause 2



Home Information


Address
City
State  Zip 
How Long At This Address:     Year Home Was Built:
Sq. Footage (excluding garage
and basement):
sq. ft.        
# of Claims In Last 3 Years:
New Home Purchase?        # Closing Date:        # Purchase Price:
Occupants



Structure Information


Updates To Electrical? Yes No If so, what year
Updates To Plumbing? Yes No If so, what year
Type
Construction
Roof
Foundation
Garage
Age of roof: yrs.



Features


Bathrooms
Deck/Porch/Patio
Fireplaces
# of Full:  
# of Half:  
Deck Sq. Ft.:  
Porch Sq. Ft.:  
Screened Patio Sq. Ft.:  
# of Chimneys:  
# of Hearths:  



Additional Features


Heating System
Security Alarm
Fire Alarm
Central Air
Central Vac
Smoke Detector
Swimming Pool
Yes
Yes
Yes
Yes
Dogs? Yes   Breed: Trampoline? Yes
Acreage? Yes   How many acres:



Additional Comments


Describe any claims/losses in the last 3 years

Please give any additional comments you feel appropriate for this quotation. If you
have additional information where there was not enough space, please enter it here.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.





Recreation Insurance


Note: Include any information that might be pertinent to your quote.

Business Insurance


Note: Include any information that might be pertinent to your quote.

Life/Health Insurance


Note: Include any information that might be pertinent to your quote.

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Rhodes Insurance Agency : An independent insurance agency serving Texas.