helpinsure.com - Consumer Form

Personal
Information

1

First Name
Last Name
Home Phone	-
Other Phone	- Ext
E-Mail Address
OK to Share E-Mail with Agents / Insurance Companies?
Best Method to Contact? To make multiple selections, hold down the Ctrl key.
Need Contact to Speak
Military Status? [To determine eligibility for certain insurers.]

Address
Information

2


Property Location
Street
City
County
Zip Code	-

Mailing Address if Different
Street
City
State
Zip Code	-

Dwelling
Information

3

Type of Dwelling
Construction Type [More Information]
Occupancy Type
Number of Stories
Square Footage
Inside City Limits?
Dwelling Value $	No commas in amount.
Reason for Needing Coverage
Rejected for Homeowners Coverage by Insurer(s)?

Survey
Information

4

The following survey information is optional and will be used to assist TDI in monitoring market conditions. This information will not be shared with insurance companies and agents. However, if you elect to complete the following information please be aware that this information may be considered public record subject to disclosure under the Texas Public Information Act.
Current Insurance Company
Claims Filed in Last 3 Years?	Yes No
Type of Claims To make multiple selections, hold down the Ctrl key.
Year Home Built

Disclosure Statement				5
	Helpinsure.com, a free service sponsored by the Texas Department of Insurance (TDI), helps Texans find insurance for their homes. Helpinsure.com and TDI need certain personal information to assist you. This information will be posted to a restricted area of Helpinsure.com for review by insurance companies and agents interested in offering homeowners coverage to participants. Any information received and maintained by TDI may be subject to release under the provisions of the Texas Public Information Act. Although by law much of the information you submit may be considered public record, portions may be confidential. For example, you may include private information protected by the doctrine of common law privacy or individual e-mail addresses protected by the Texas Public Information Act. Sharing this information for purposes of processing your request does not waive these confidentiality protections. If you would like more information about the public or confidential nature of information maintained by TDI, please consult our Open Record Policy at www.helpinsure.com/help/open.html and our Web Site Privacy Policy at www.helpinsure.com/help/privacy.html. The form you are about to fill out is encrypted to meet privacy requirements. Access and Correction of Personal Information With few exceptions, you are entitled to be informed about the information that Helpinsure.com and TDI collects about you. Under sections 552.021 and 552.023 of the Texas Government Code, you have a right to review or receive copies of information about yourself, including private information. However, TDI may withhold information for reasons other than to protect your right to privacy. Under section 559.004 of the Texas Government Code, you are entitled to request that TDI correct information that TDI has about you that is incorrect. For more information about the procedure and costs for obtaining information from TDI or about the procedure for correcting information kept by TDI, please e-mail the Agency Counsel Section of TDI's Legal & Compliance Division at agency.counsel@tdi.state.tx.us or review our Corrections Procedures at www.helpinsure.com/help/correct.html. Please understand that the information you provide through this form will be disclosed to insurance companies and agents in an effort to help you obtain coverage for your home. Your information will be maintained for 30 days. Before your information is removed, TDI will contact you by mail, phone, fax or e-mail to determine (1) whether you have obtained coverage for your home or (2) whether you want to re-enroll in Helpinsure.com's program to match homeowners needing coverage to insurers and agents selling coverage. While completing this form will not guarantee that you will receive an offer to insure your home, we hope that you will provide us feedback about this service. Please select "Yes" and click Submit if we have permission to post your information from above to a restricted area of our Web site. If you are unsure or have any questions about the application process, please call 1-866-695-6873 weekdays from 8 a.m. to 5 p.m.
	Yes: