	Kevin E. Severance Insurance Agency
	Ph: (281) 333-3100 - Fax. 866-796-0610

Renter Insurance

Please fill in the request form below.
Note that fields marked with a * are required entries.
When the form is complete, click on the "Send Request to Kevin E. Severance Insurance Agency" button.

Insured Information

Customer No.
Kevin E. Severance Insurance Agency

EMail Address *
(Quote will be returned to this address.)

Name of 1st Insured *

Company

Name of 2nd Insured

Address

City/State/Zip (all three fields required) *

County *

Phone Number (with Area Code) *

Social Security Number

Driver License

Mail

Property Information
Address of the property to be quoted:
City:
State:
ZIP code:
Please select the property type:
Do you currently own (or are you in the process of purchasing) this property? yes no
Do you now reside, or plan on residing at this property within the next 12 months? yes no
How much Residence coverage do you want?
How much personal liability coverage do you want
Please select your desired deductible
Approximate year property built:
Approximate livable square footage of residence: (Excluding basement, if any):
Is this your primary or secondary residence? primary secondary
Have you reported any claims or losses to your insurance within the past 5 years? yes no
Is business or farming conducted on this property? yes no
Do you have any of the following breeds of dogs: Chow, Doberman, German Shepherd, Pit Bull, Rottweiler, Wolf Hybrid, or mix of these? yes no
House design
Number of bedrooms
Number of bathrooms
Exterior wall type (60% or more):
Roof type
Roof age
Garage type
Describe Foundation or Basement
Wiring type
Service panel type
Burglar Alarm
Central Fire Alarm
Fire station
Fire hydrant
Municipal location
Please describe the heating system
Number of gas, pellet or wood fireplaces or stoves
Is your home prone to flooding or located in a designated flood plain?
Property Accessories (Check all that apply) Dead Bolts Air Conditioning Swimming Pool Smoke Detectors Covered Deck/Patio Tennis Court Fire Extinguisher Uncovered Deck/Patio Trampoline Indoor Fire Sprinkler