Welcome to Salazar Insurance Agency

Home Insurance Quote

Please complete the form below, and we will contact you shortly.
Any items marked with an * are required.

Applicant Information

Name:

Referred By:

E-mail:

Today's Date:

Phone:

Date of Birth:

SSN:

TxDL #:

Address:

City:

Zip Code:

FARA Code:

Home Information

Year Built:	Total Sq. Ft:	Stories:
Dwelling Amount:	Construction Type:	Roof Type:
Roof Age:	Plumbing Age:	Electric Age:
Within City Limits:	Alarm System:	Garage Type:
Pool Fenced:	Slide:	Diving Board:

Occupant Information

Occupant 1	Occupant 2	Occupant 3
Name:	Name:	Name:
Age:	Age:	Age:
TxDL:	TxDL:	TxDL:

Insurance History

Explain any claims, losses and/or bankruptcy within the last 5 years:

Who is your current policy with:

Discounts

Home Alarm System / Anti-Theft Device
Other Discount

End User Liscense Agreement

By submitting this request, you the end user understand that there is no guarantee of coverage, and no coverage is in force until an actual application is approved and a premium received by Showery Insurance. An authorized representative of Salazar Insurance Agency will contact you shortly about this quote request.

Also, by submitting this request, you certify that the statements made on thsi quote request are accurate to the best of your knowledge, and that this quote request does not constitute a part of any policy issued.

You can review and will have an opportunity to change the information submitted by clicking the preview button, and by written request made to dgsalazar@salazarinsuranceagency.com.