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Texas Mortgage Payment Protection Insurance

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					                      Texas Insurance Exchange Group                                         Auto & Home Insurance Quote Sheet
Date:                                                                                                                                                                 Nov-07

Name

Current Address                                                                                     City                                       Zip



Email                                                                                               Current Home Carrier

Home Phone                                        Cell                                              Current Auto Carrier

Day Phone                                         Fax                                               Exp./Closing Date

Vehicle Information
                           Yr./Make/Model                                    Use       Commute        Lienholder                      Losses     Tickets              Notes

1                                                                                                       Y       N

2                                                                                                       Y       N

3                                                                                                       Y       N

4                                                                                                       Y       N

Driver Information/Other Residents
            Name on Driver's License                         Date of Birth                   Driver's Lic. #                  Social Sec #       Def Dr           G Student

1
2
3
4
5
Coverage Selections
                 BI                      PD                 PIP                     UMBI                         UMPD                OTC Ded    Coll Ded              Rental

             25/50                       25                 2500                                                                    < 250            250

             50/100                      50                 5000                   25/50                             25                250           500              25/750

            100/300                     100              10000                     50/100                            50                500           1000             30/900

    250/500               500                                                  100/250                              100                1000      Liability         40/1200

Rate Quote
                 Annual Premium                              Semi Annual Pay Program                                  Monthly                               Towing

        $                                                    $                                              $                                   40        80           120


Home Information                 County_____________ Buy/ Move in year?________
     Yr Built            Sq Ft          Baths            Stories         Attach         Garage         Fireplace            Deck       Patio         Pool          Diving B

                                                                       Y / N
    Const Type         Foundation      Type          Age of Roof        Security                  Fire Protection                     Gated                    Dogs

                                                                        C / L          Central / S Detectors / Sprinkler

Home Owners___________                    Fire & EC _____________                                Tenants_________________
                                                Liability                          Medical                  Wind / Hail       Deductible             Other Peril Deduct


                                         300,000 / 500,000             $1,000 or $_______                       1%        or _________ %             1%        or ______ %
Premium Costs                    Closing Date____________________                     Bank/Mortgage _____________________
                 Annual Premium                                    Down Payment                                                                      Monthly Payments

        $                                                    $                                                                                        $
Discounts:             EFT           Advance Purchase                        Interior Inspection                     Auto/Home

				
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