(210) 525-8438
San Antonio, TX
Dan Miller Insurance Agency
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Contact Name
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Date of Birth
Occupation
Property Location Under Construction
Address
City
State
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County
Mailing Address / Current Address
Address
City
State
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Insurance Information
Deductible Desired
$100
$250
$500
$1000
$1500
$2000
$2500
$5000
Amount of Liability Desired
$100,000
$500,000
$300,000
$200,000
$1,000,000
Hurricane Coverage Desired?
Yes
No
Earthquake Coverage Desired?
Yes
No
Windstorm Coverage Desired? (not applicable in all states)
Yes
No
Dwelling Information
Estimated Replacement Cost
Square Footage
Roof Type
How Many Floors?
1 Story
1.5 Story
2 Story
Bi-Level
Tri-Level
Other
Type of Construction
Wood
Stucco
Masonry
Brick Veneer
Aluminum Siding
Other
Other Home Features
(check all that apply)
Dead Bolts
Fire Extinguisher
Located within 5 miles of Fire Station
Located 1000 feet from Fire Hydrant
Home Located within City Limits
Claims
Date of Claim
Amount Paid
Claim Type
Description
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