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Home + Renters
Name
*
First Name
Last Name
Homeowners
Homeowners
New Business
New Business
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). OR if you can send us your current Dec Page, you can upload this at the end of the form.
*
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.
*
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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