Renters Quote Request

1
Which agent are you working with at The Insurance Pad?* This field is required.(If you haven't spoken with an agent, choose one below)
kim@theinsurancepad.com
lexi@theinsurancepad.com
brittany@theinsurancepad.com
2
Customer's Name* This field is required.
First Name
Last Name
3
Do you have an auto insurance or any other policy with us now?* This field is required.
YESNO
4
Your (or Named Insured's) Date of Birth
Date
Month
Day
Year
5
Who is your auto insurance with?
6
Do you have renters insurance now?
YESNO
7
Who is your renters insurance with now?
8
When does your current renters insurance expire?
Date
Month
Day
Year
9
Phone Number* This field is required.
Please enter a valid phone number.
10
Email* This field is required.
example@example.com
11
Address* This field is required.Address you want your renters insurance coverage. Please include apartment number if applicable.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
12
Date moved/moving in:* This field is required.
Date
Month
Day
Year
13
Do you have any pets? * This field is required.
YESNO
14
If you have a pet(s), what kind?
Cat
Dog
Exotic animal
Other
15
If dog(s), what breed(s)?
16
If "other" pet, please explain:
17
Has your pet every bitten anyone / have any history of biting?
YESNO
18
Including yourself, how many household residents?* This field is required.(Including yourself, how many total people live in your household, regardless of age)
1
2
3
4
More than 4
19
Fuel source for heat?* This field is required.
Gas
Electric
Kerosene
Oil
Other
20
Is there a deadbolt lock on the door(s)? * This field is required.
YESNO
21
Are there working smoke detectors in the home? * This field is required.
YESNO
22
Is there / are there working fire extinguishers in the home?* This field is required.
YESNO
23
Do you use any supplemental heat? * This field is required.(Do you use anything in addition to your furnace to heat your home like space heaters, etc)
YESNO
24
What is the structure of the home/building?* This field is required.(What is the exterior of your home made of - Does it have siding, or is it brick, or something else.)
Frame (vinyl/aluminum siding)
Brick/Masonry
Other
25
Is there a basement? * This field is required.
YESNO
26
Would you like coverage for water backup of sewer / drains?* This field is required.(Do you want coverage for your property in the event that water backs up in your basement through sewer, drain, or sump pump)
YESNO
27
Do you have a trampoline? * This field is required.
YESNO
28
IF there is a trampoline, is it netted?
YESNO
29
IF there is a trampoline, is the yard fenced in?
YESNO
30
How much coverage do you need for your personal property?* This field is required.(If you had to replace all of your belongings, how much do money do you think you would need? This would include things like furniture, TVs, clothing, dishes, silverware, sheets, towels, etc.)
$20,000
$25,000
$30,000
$35,000
$40,000
$45,000
$50,000
Other
31
If other please explain:
32
Do you have any high value items such as artwork, cameras, computer equipment, jewelry, furs, firearms, or any sort of collection valued at more than $1,000 per item, piece or collection?* This field is required.(There are limits to the amount of coverage a company may provide in certain categories. So if you have any high value items or collections, we need to be sure you have coverage for them.)
YESNO
33
If you would like coverage for the high value item(s), please describe the item(s) and indicate value(s) :
34
Is your landlord / management company requiring coverage?* This field is required.
YESNO
35
What limit of liability are you requesting / your landlord requiring?* This field is required.
$100,000
$300,000
$500,000
Other
I don't know
36
Will you be renting your property to others?* This field is required.(VRBO, airbnb, etc)
YESNO
Should be Empty: