Tenant's Insurance Quote Request
for a Primary Residence, tenant occupied
Name of Insured person:
*
First Name
Middle Initial
Last Name
Suffix
Phone Number
*
-
Area Code
Phone Number
Email (if no email, please enter "None"
*
example@example.com
Your date of birth
*
-
Month
-
Day
Year
Date
Gender:
*
Male
Female
Marital/Civil Status:
*
Single
Married
Divorced
Widowed
Other
Occupation:
*
If none, write "Unemployed", "Disabled", or "Retired"
Is there a 2nd name on the Lease? (would need to be named on the policy)
*
Yes
No
Named Insured #2
First Name
Middle Initial
Last Name
Suffix
Relationship to first Insured:
Spouse
Child
Parent
Other
Email (Insured #2)
example@example.com
Date of Birth (Insured #2)
-
Month
-
Day
Year
Date
Location to be covered:
*
Street Address
Street Address Line 2
City
State
Zip Code
How long have you lived at this location?
*
0 years, I'm moving in for the first time
0 - 2 years
over 2 years
Effective Date you want:
*
-
Month
-
Day
Year
Date
How many units/apartments are in the entire building?
*
Prior Address if under two years ago:
Street Address
Street Address Line 2
City
State
Zip Code
Will you be moving into the apartment on the effective date?
Yes
No
I'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 insurance
No, I have lived here, but have not had insurance
No, 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?
Yes
No
What total amount of coverage do you want for your personal property?
*
Furniture, appliances, rugs, clothing, etc.
Style of Building
*
Please Select
1 story or Ranch
2 story
Cape Cod
Split Level
BiLevel
Townhouse
3 Story
Duplex (2 family)
Triplex (3 family)
Apartment Complex
Rowhome
Construction of building
*
Please Select
Frame
Masonry (wood frame)
Masonry (solid brick)
Metal
Stucco
Modular
Mobile Home
Foundation Type
*
Please Select
Crawlspace-elevated
Crawlspace-subgrade
Unfinished basement
Finished basement
Slab
On piles
Garage?
*
Please Select
No Garage
Attached garage
Detached garage
Type of Heat
*
Please Select
Oil
Natural Gas
LP Gas
Electric
Geo Thermal
No central heat
Location of oil tank
Please Select
Outside above ground
Basement
Underground
Do you have any dogs?
*
Yes
No
Describe Breed for each dog (please do not write "mutt" or only "mixed")
Has the dog had any bite history?
No
Yes
Is there a Swimming Pool (not if apartment complex)?
*
Yes
No
What type of pool?
In Ground
Above Ground
Does the pool have a Diving Board or a Slide (check all that apply):
No Diving Board or Slide
Diving Board only
Slide only
Diving Board AND a Slide
Is the pool gate locked?
Yes
No
Is there a Fire Hydrant within 1000 feet?
*
Yes
No
When was the Roof updated?
*
This year
1-10 years ago
11-20 years ago
over 20 years ago
When was the Furnace updated/replaced?
*
This year
1-10 years ago
11-20 years ago
over 20 years ago
N/A -i don't have a furnace
Has the Plumbing and Wiring been updated within the past 25 years?
*
Yes
No
Please provide more detail why plumbing and wiring have not been updated:
Is there a Woodstove in the apartment?
*
Yes
No
Do you have any Business conducted in or on the Property?
*
Yes
No
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?
*
No
Yes, but I'm not interested in adding them to this policy
Yes, 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 me
Call me
It's okay to text me
Name of person completing this form
*
First Name
Last Name
How did you find us?
*
Please Select
Google Search
Referred by a friend
Referred by realtor
I am already a current client of Henry D Young Inc
Other
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?
Please Select
No, doesn't matter
Ares
Carol
Debbie
Jason
Tammy
If you would like to upload a copy of your current Homeowners insurance policy, please use this:
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