Herbert M. Sheaner, Jr. 
Insurance Agency

Tell us about you.

*First name
*Last name
*Mailing address
Address (cont.)
*City
State	Texas
*Zip code
Work phone
Home phone
Fax
*Email
Preferred means of contact	(choose one) Email Work phone Home phone Fax Mail
*Social Security Number	A CLUE report will be requested to determine the best pricing available.  The CLUE is based on information from your credit history and 3 year loss experience.
* Date of Birth
*Clear credit history	(choose one) Yes No

Tell us about your property.

*Street address of property to be covered
Address (cont.)
*City
State	Texas
*Zip code
*County
Type of property	(choose one) Owner occupied Tenant-occupied dwelling Vacant dwelling
*Amount of insurance desired $
To be occupied by	(choose one) Named insured (me) Someone other than named insured
Vacant, unoccupied, under construction	(choose one) Yes No
*Year built
If over 20 years old, give the update year for applicable items	Heating Electrical Plumbing Roof
Heating and Cooling (check all that apply)	Central heat Central air Space heater A/C window unit
*Construction	(choose one) Brick veneer Frame Aluminum siding Vinyl siding Stucco
*Age of roof
Roof type	(choose one) Wood shingle Composition Slate
Foundation	(choose one) Slab Pier and beam
Square feet
Stories	(choose one) 1 1-1/2 2 2-1/2 3
Garage type	(choose one) None Attached Detached
Garage size	(choose one) No garage 1 car 2 cars 3 cars 4 cars
Full baths	(choose one) 1 2 3 4 5
Half baths	(choose one) None 1 2 3 4 5
Fireplace	(choose one) Yes No
Swimming Pool	(choose one) Yes No
Animals on premises	(choose one) Yes No
If you answered "Yes" about animals, please describe breed.

 

Security
*Deadbolt on all doors	(choose one) Yes No
*Smoke alarms	(choose one) Yes No
*Monitored alarm system	(choose one) None Fire Burglar Fire and burglar

Tell us about your insurance history.

Current insurance company
Renewal date
*Has insurance been declined, cancelled, or nonrenewed in the last 3 years?	(choose one) Yes No
*Have you had any claims or losses in the last 3 years?	(choose one) Yes No
If you answered "Yes" about claims or losses, please describe. Include date and amount paid.

Please provide any additional information or comments.