Language
English (US)
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Home + Renters
Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Is there a second owner or co-applicant?
*
Yes
No
Co-applicant Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Relation
*
Please Select
Spouse
Relative
Non-Relative
Property Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is this a mobile home?
*
Yes
No
Do you rent or own?
*
Rent
Own
Is this your primary residence?
*
Yes
No
Is the home rented out to others?
*
Yes
No
Rental Exposure
*
Please Select
Long term rental (one year)
Short term rental (less than one year)
AirBnB
Value of personal property (if any)
*
Is this a new purchase within the last 45 days?
*
Yes
No
Purchase Price
*
Is the home currently insured?
*
Yes
No
How long have you lived here and how long has the home been uninsured?
*
Current insurance carrier
*
Current policy expiration date
*
-
Month
-
Day
Year
Date
Have any updates been made since original year built that would increase the homes value?
*
Yes
No
What updates have been made?
*
Do you have a burglar alarm?
No
Yes - Central - Connected to a monitoring service that will contact emergency services if an alarm is triggered. (Proof Required)
Yes - Local - Will alert the homeowner on an app or play a sounds, but will not contact emergency services.
Do you have a fire alarm?
No
Yes - Central - Connected to a monitoring service that will contact emergency services if an alarm is triggered. (Proof Required)
Yes - Local - Will alert the homeowner on an app or play a sounds, but will not contact emergency services.
Is there a swimming pool?
*
Yes
No
Is there a trampoline?
*
Yes
No
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Mobile Home
Year Built
*
Manufacturer
*
Length
*
Width
*
Single or double wide?
*
Please Select
Single Wide
Double Wide
Is the home in a mobile home park/community? If yes, what is the name?
*
Do you want Replacement Cost or Actual Cash Value?
*
Replacement cost- will insure the home for what it costs to replace, regardless of depreciation. (More coverage for a higher price) After a claim is settled, you will end up with the same as what you currently have.
Actual Cash Value- will insure the home for what it costs to replace your home after depreciation of materials (Less coverage for a lower price) After a claim is settled, you will get back a portion of what you had, whatever it is currently worth.
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Renters Insurance
How much personal property coverage do you want? ($15,000 minimum)
*
How much liability coverage do you want? ($100,000 mimimum)
*
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Please upload any documents that may help us quote (prior dec page, etc.)
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Referral Partner:
Please Select
N/A
Rosa
Luciana/Nextcellent
EZ Auto
Next Car
Other
Customer Language:
Please Select
English
Portuguese
Spanish
Agent Name:
Comments:
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Month
-
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Date
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