Orlando Reyes Insurance, L.L.C. - Texas Insurance for Automobile, Life, Health, Business, Commercial Vehicle, Watercraft, Mobile Home Insurance, based in Arlington, Texas

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ONLINE RENTERS QUOTE

Simply fill out the information below as thoroughly as possible and submit your application. It will be sent to us, in confidence, and we will process your information and contact you shortly with your quote.

Personal Information

Name:
Address:
City:	County:
State: Zip:	Email Address:
Day Phone:	Night Phone:
Cell Phone:	Fax:
Best Time To Call:
Occupation:
Date of Birth:	Social Security Number:
Spouse's DOB:	Spouse's SS#:
Is this a rental property?
How did you hear about us? If "Friend/Co-Worker", Name: If "Other", please explain:
How would you like to receive your quote?

Current Renters Insurance Information

Company Name (not agency):
Policy Expiration Date:
Premium Amount: $
Amount Insured For: $
Term: If Other:

Home Information

Year Home Was Built:

Claims In Last 3 Years:
Claim 1: Amount Paid:
Claim 2: Amount Paid:
Claim 3: Amount Paid:
Claim 4: Amount Paid:

Structure Information

Type Construction

Roof Age of roof: yrs

Foundation

Garage

Features

Bathrooms
# of Full:
# of Half:

Deck/Porch/Patio
Deck Sq. Ft.:
Porch Sq. Ft.:
Screened Patio Sq. Ft.:

Fireplaces
# of Chimneys:

Additional Features

Heating System	Security Alarm
Central Air Central Vac	Fire Alarm Smoke Detector

Possible Discount Factors

Do we carry your auto, life, or other insurance?

Policy Numbers:

Are you a ?

Are you over the age of 50?

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.

One of our representatives will respond to your submission as soon as possible.

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