Personal

MetroplexInsurance.com offers the following personal coverages:

Home	Boats/Personal Watercraft
Auto	Renters
Mobile Homes	Umbrella
Farm and Ranch	Motorcycles
Personal Article Floaters

Please fill out the form below for a no obligation Auto and/or Home quote.
If you are unsure of the information to fill out, please just complete the "General"
section and we will contact you:

General Information
*Full Name
*Spouses Full Name
*Address
*City
*State
*Zip Code
*Email
*Phone
Work Phone
*Date of Birth
*Occupation
*Years at current Job
*SSN
*TX Drivers License # of all drivers
Home Owners (Optional)
Full address of new home or rental property
Years lived in area
Years lived in your home
All addresses of the last 3 years
Level of Water/Plumbing coverage	Full   Some   None
Describe all claims in the last 5 years
Year home built
Total sq. ft.
What % is siding
What % is stucco
What % is brick/stone
Stories	1   1 1/2   2   3
Garage	attached   detached   carport   none
How many car garage	1   2   3   4
Living area over garage	Yes   1/2   No
Number of bedrooms
Number of bathrooms
Gameroom	Yes   No
Study	Yes   No
Central Heat	Gas   Electric
How many HVAC units
How many fireplaces
Pool	Yes   No
Diving board	Yes   No
Pool slide	Yes   No
Spa/Hot tub	Yes   No
Fenced yard	Yes   No
Trampoline	Yes   No
Dog(s)	Yes   No
What kind of dog(s)
Roof	Comp   Wood   Other
Roof - How many layers
Roof age in years
Purchase price $
Loan amount $
Current insurance company
Current wind/hail deductible $
Current fire deductible $
Smoker	Yes   No
Over age 50	Yes   No
Monitored alarm	Yes   No
Dead bolts (all doors)	Yes   No
Smoke alarms	Yes   No
Fire extinguisher	Yes   No
New construction	Yes   No
Auto (Optional)
Academics, Drivers Training or Defensive Driving Dates of Completion
Citations, Accidents, or Claims
Current insurance carrier
When does your policy renew
Auto 1 (Optional) For more than 1 auto, fill out form again for each auto please
Principal driver name
Principal driver is	Male   Female
Secondary driver name
Secondary driver is	Male   Female
List all other drivers age and sex
Year
Make
Model
Alarm	Yes   No
Select all that apply	2-Dr 4-Dr Convertible SUV 4x4 Reg Cab Pickup Ext. Cab Pickup
Vin #
One-way commute mileage
Current comprehensive deductible $
Current collision deductible $
Current towing deductible $
Current rental deductible $
Current auto liability limits $
Current bodily injury/property damage $
Current medical/personal injury $	0   2500   5000   10000
Current uninsured/underinsured $
Requested comprehensive deductible $
Requested collision deductible $
Requested towing deductible $
Requested rental deductible $
Requested auto liability limits $
Requested bodily injury/property damage $
Requested medical/personal injury $	0   2500   5000   10000
Requested new uninsured/underinsured $