Harris County Insurance Center, LLC

Baytown Agency
608 Rollingbrook Drive
Baytown, Texas 77521
(281) 427-6511
Pasadena Agency
825 Southmore Ave
Suite 202
Pasadena, Texas 77502
(713) 481-0700
Houston Metro Agency
4221 Telephone Road
Houston, Texas 77087
(832) 500-3666
(713) 641-1234
Deer Park Agency
110 W Pasadena Blvd
Deer Park, Texas 77536
(281) 479-5248
Houston Agency
13030 Woodforest Blvd
Suite C
Houston, Texas 77015
(832) 582-8500

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Property Insurance Quote Request Questionnaire

General Information
Contact Name:
Phone Number:       FAX
E-Mail Address:
Name of Business
Business Address:
Business Address 2:
City - St - Zip:
Location/address for this quote.
  Please submit a copy of this form for each building or locations.
  If your business is home based, complete this form on the business portion of the home.
What is the desired Property Deductible?

Is the property within 1,000 feet of a fire hydrant?   YES NO


Is the business within 5 miles of a Fire Station?   YES NO


What is the 100% replacement value of the business personal property (include value of business contents, fine arts, computer hardware and software)?

What is the construction of the building where the business is located?
Joisted masonry/Brick
Non-combustible Steel
Non-combustibleTtilt-up concrete masonry
Fire resistive

If the construction of the building is not known, please provide details on the materials used for the roof, floors and walls.


What is the square footage of the space occupied by the business?  


Is the business the sole occupant of a free standing building?   YES NO


Does the building have an automatic sprinkler system covering 100% of the premises?   YES NO


Does the business have a central station burglar alarm?   YES NO


Is there any use of grills or deep fat frying in your business operations or in any other businesses in your building? (i.e. restaurant in the same building)   YES NO

13 Please indicate whether the following optional coverages are desired:

  a) Earthquake Coverage (not available in all areas):   YES NO


  b) Sprinkler Leakage - Earthquake   YES NO


  c) Flood Coverage (not available in all areas):   YES NO


  d) Computer Mechanical Failure and Computer Virus Coverage ($100,000 limit)   YES NO


  e) Systems Breakdown Coverage? (i.e. boilers, pressure vessels, AC units, etc.   YES NO


  f) Mine Subsidence Coverage (KY, IL, IN, WV only)   YES NO


  g) Business Income from Dependent Properties ($10,000 limit)   YES NO


  h) Personal Property Off Premises and Property in Transit Limited International Extension Endorsement   YES NO


  i) Business Income Sub-limit   YES NO

    If yes, choose limit option desired:

  j) Business Income Waiting Period Deductible (24 hours)  YES NO


  k) Business Income Off Premises Power Failure ($10,000 limit)   YES NO

14 Please indicate whether any of the following exclusions are desired:

  a) Business Income Exclusion   YES NO

  b) Theft Exclusion   YES NO

  c) Windstorm and Hail Exclusion   YES NO

  d) Stock Exclusion   YES NO


What is the total maximum daily value of money and securities (i.e. checks) on the premises?  

The policy includes limits of $10,000 inside the business and $2,000 while being delivered to the bank. If higher limits are desired, choose one of the following options: (Please note that in order to receive higher limits use of a safe on premises is required.)
$20,000 / $4,000
$30,000 / $6,000
$40,000 / $8,000
$50,000 / $10,000

If loss of refrigeration coverage is desired, what is the total value of property subject to refrigeration?  


Most property coverage forms provide for coverage similar to the limits listed below.

Fire Dept. Service Charge/
Fire Extinguisher Recharge
Money Orders and Counterfeit Currency
Forgery and Alteration $2,500 Increased Construction Cost (after a loss) $5,000
Glass $2,500 Signs $2,500
Customers’ Goods on Premises $10,000 Back-up of Sewer/Drains $2,500
Personal Property Off Premises $5,000 Property In Transit $5,000
Valuable Papers/Records on premises $10,000 Accounts Receivable at the premises $10,000
Employees Dishonesty - ERISA $2,500    

If you will require limits higher than shown above, please indicate here:

  Complete questions #18 to #23 only if interested in purchasing insurance for the building. Home based businesses do not need to complete these questions.

What is the 100% replacement value of the building?


Are you interested in having one blanket limit for both building and business personal property? YES NO

20 What is the square footage of the entire building?
21 How many stories in the building?
22 What is the original year the building was built?
23 If the building(s) is over 30 years old, please list the year each of the following was updated:
Please hit the Submit Button to send your Quote Request. We will get back to you with your free, no obligation quote as soon as possible.

Copyright @ 2007 Harris County Insurance Center - All Rights Reserved
Offices in Houston, Baytown, and Pasadena Texas.
Note: As stated in our "Terms of Service" (TOS) agreement, descriptions of insurance coverage on this web site are for informational purposes only and may not apply, or be included on your policy. Please contact us to confirm coverage provided on your insurance policy or policies your are contemplating purchasing.