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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 co-applicant?
*
Yes
No
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Co-applicant Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Relation
*
Please Select
Spouse
Relative
Non-Relative
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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
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Homeowners
Is this a new purchase within the last 45 days?
*
Yes
No
Purchase Price
*
Is the home currently insured?
*
Yes
No
Current insurance carrier
*
Current policy expiration date
*
-
Month
-
Day
Year
Date
Can you provide your current coverages? (This will help us quote apples to apples)
*
Yes
No
Coverage A - Dwelling
*
Coverage B - Other Structures
*
Coverage C - Personal Property/Contents
*
Coverage D - Loss of Use
*
Coverage E - Personal Liability
*
Coverage F - Medical Payments
*
Wind/Hail Deductible
*
All other Peril Deductible
*
Personal Property Replacement Cost?
*
Yes
No
25% Extended Replacement Cost
*
Yes
No
Any updates made to plumbing, roof, or hvac? Explain below.
*
Other Structures- Covers any detached buildings or structures on your property that are not physically connected to your primary residence, such as a detached garage, shed, gazebo, fence or swimming pool.
I want this coverage
I do not want this coverage
Other Structures Coverage Amount:
Personal Contents-Covers the cost of replacing your personal belongings, such as your furniture, decorations, jewelry and clothing.
I want this coverage
I do not want this coverage
Personal Contents Coverage Amount:
Personal Liability-Covers the costs of injuries to someone on your property, or damage you caused to someone else's property.
I want this coverage
I do not want this coverage
Personal Liability Coverage Amount:
Loss of Use-Covers the costs of living away from home if your home is damaged and needs to be repaired or rebuilt. This can include hotel bills, apartment rent, and restaurant meals.
I want this coverage
I do not want this coverage
Loss of Use Coverage Amount:
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.
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Home Usage
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)
*
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Mobile Home
Is this a new purchase?
*
Yes
No
Purchase Price
*
Is the home currently insured?
*
Yes
No
Current Carrier
*
Current policy expiration date
*
Current Value
*
Length
*
Width
*
Single or double wide?
*
Please Select
Single Wide
Double Wide
Year Built
*
Manufacturer
*
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.
I’d like to understand the difference
Is the home in a mobile home park/community? If yes, what is the name?
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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 (identification, prior coverage, etc.)
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