Tenant Insurance Quote Request

Tenant's Insurance Quote Request

for a Primary Residence, tenant occupied
Name of Insured person:*

First NameMiddle InitialLast NameSuffix
Phone Number*

Area CodePhone Number
Email (if no email, please enter "None"*
example@example.com
Your date of birth*

MonthDayYear
Date
Gender:*

MaleFemale
Marital/Civil Status:*

SingleMarriedDivorcedWidowedOther
Occupation:*
If none, write "Unemployed", "Disabled", or "Retired"
Is there a 2nd name on the Lease? (would need to be named on the policy)*

YesNo
Named Insured #2

First NameMiddle InitialLast NameSuffix
Relationship to first Insured:

SpouseChildParentOther
Email (Insured #2)
example@example.com
Date of Birth (Insured #2)

MonthDayYear
Date
Location to be covered:*

Street Address

Street Address Line 2

CityState

Zip Code
How long have you lived at this location?*

0 years, I'm moving in for the first time0 - 2 yearsover 2 years
Effective Date you want:*

MonthDayYear
Date
How many units/apartments are in the entire building?*
Prior Address if under two years ago:

Street Address

Street Address Line 2

CityState

Zip Code
Will you be moving into the apartment on the effective date?

YesNoI'm already living in the apartment
When do you plan to move into the house?
Do you currently have insurance on this Location?*

Yes, I currently have insuranceNo, I have lived here, but have not had insuranceNo, I'm just now moving into this apartment
When did your most recent policy cancel?
Is your current insurance company Cancelling or Non-renewing your policy?

YesNo
Why is your current company cancelling your policy?
What total amount of coverage do you want for your personal property?*
Furniture, appliances, rugs, clothing, etc.
Style of Building*
Construction of building*
Foundation Type*
Garage?*
Type of Heat*
Location of oil tank
Do you have any dogs?*

YesNo
Describe Breed for each dog (please do not write "mutt" or only "mixed")
Has the dog had any bite history?

NoYes
Is there a Swimming Pool (not if apartment complex)?*

YesNo
What type of pool?

In GroundAbove Ground
Does the pool have a Diving Board or a Slide (check all that apply):

No Diving Board or SlideDiving Board onlySlide onlyDiving Board AND a Slide
Is the pool gate locked?

YesNo
Is there a Fire Hydrant within 1000 feet?*

YesNo
When was the Roof updated?*

This year1-10 years ago11-20 years agoover 20 years ago
When was the Furnace updated/replaced?*

This year1-10 years ago11-20 years agoover 20 years agoN/A -i don't have a furnace
Has the Plumbing and Wiring been updated within the past 25 years?*

YesNo
Please provide more detail why plumbing and wiring have not been updated:
Is there a Woodstove in the apartment?*

YesNo
Do you have any Business conducted in or on the Property?*

YesNo
Describe the Business conducted on the Property
Jewelry, Antiques, Collections, and Fine Arts have limitations on the basic policy. Do you have any items of this type?*

NoYes, but I'm not interested in adding them to this policyYes, I would like to inquire about adding them to this policy
Please describe the item(s) and the Value of each?
example: Ladies diamond ring, value $3,000
Any comments or special requests?
If no, please leave blank
How would you like us to contact you? (you can check more than one)*

Email meCall meIt's okay to text me
Name of person completing this form*

First NameLast Name
How did you find us?*
Were you referred to us by someone? If so, please let us know who referred you so we can send them a thank you.
Do you want this quote request sent to a particular person?
If you would like to upload a copy of your current Homeowners insurance policy, please use this:

Cancelof
Should be Empty:

Tenant's Insurance Quote Request