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14074 Trade Center Drive, Suite 104  Fishers, IN  46038
Phone: (317) 774-7740     Fax: (317) 774-7741
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 First Name
 Last Name
  Middle Name

 City (Indiana only)
                            State (Indiana only at this time)
 Zip Code

  Home Phone
  Daytime Phone (if different)

 Home - Year Built                               Is home mostly brick? Y / N

  Home - County           basement / crawl / slab?

  Home - Township         any animals - type?

  Home - square feet         number of stories?

  Home - coverage amount        
Note: coverage amount on home needs to be 100% replacement cost. Agent will inspect outside of home to determine replacement cost.

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Luxor Insurance Group
14074 Trade Center Suite 104
Fishers, IN  46038