Grace White Insurance
P.O. Box 5190
Pasadena, TX 77508
Phone: 281-998-9500
Fax: 281-487-5809
   

Renters Insurance Quote Form
     
  Personal Information  
     
 
First Name* Last Name*
E-mail* Date of Birth*
  (mm/dd/yyyy)
Social Security Number*
Home Phone* Work Phone
Cell Phone Fax Number
Address*
City* State*
Zip* County*
     
  Safety Features  
     
 
Within 1000' of fire hydrant
Yes No
Within 5 miles of fire station
Yes No
Fire Extinguisher
Yes No
Home Fire Sprinkler System on each floor
Yes No
Smoke Detectors on each floor
Yes No
Deadbolt locks on all edxterior doors
Yes No
24 Hour Manned Security Service
Yes No
Home located on a paved road
Yes No
 
     
  Property information  
     
 
Year Built
Moved In
Number of Units
Number of Stories
Prior Insurance Co
 
     
  Claims Informations  
     
 
Number of Claims
Claim Description  
 
     
  Coverage Information  
     
 
Contents Coverage
Premise Liability
Deductible
Wants Contents Replacement Coverage
If Yes, Minimum Coverage amount $15,000
In order to give you an accurate quote for your Renters Insurance we need additional information
Please enter your SSN / Social Security Number
  ex: 011-88-9191
Note; We use a Risk Assessment evaluation score which is based on several factors including your personal credit score /rating.
 
     
 
 


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