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Please submit your information to obtain your Renters Benefit Package Insurance Policy
Contact Information
Primary Name Insured
*
First Name
Last Name
Primary Name Insured Date of Birth
*
-
Month
-
Day
Year
Date
Additional Insured (If applicable)
First Name
Last Name
Additional Insured Date of Birth (If applicable)
-
Month
-
Day
Year
Date
Additional Insured ( If applicable)
First Name
Last Name
Additional Insured Date of Birth (If applicable)
-
Month
-
Day
Year
Date
Phone Number
*
E-mail
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Policy Effective Date
-
Month
-
Day
Year
(Date Moving In)
Personal Property Coverage
(This is the amount you have for electronics, furniture and other personal property)
Any Additional Notes?
Terms and conditions
*
Max amount Benefits Renter Package allows is for an annual policy of $205, If Premium is higher then it will by renters billed.
Policy is subject to acceptance by the insurance companies
I agree to receive SMS notifications and promotional offers from Carlos Perez - Farmers Insurance Agency.
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