Renters Questionnaire
Property Information
How did you hear about Missouri Farm Bureau?
Existing Member
Referral
Social Media
Print Media Ad
Other
If existing Missouri Farm Bureau member, please provide Membership Number
Name (Primary)
*
First Name
Last Name
Date of Birth (Primary)
*
-
Month
-
Day
Year
Date
Name (Spouse)
First Name
Last Name
Date of Birth (Spouse)
-
Month
-
Day
Year
Date
Address (Primary for coverage)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you filed a claim of loss in past five (5) years?
*
Yes
No
Other
If "Yes" of claim loss, please provide detailed reason(s) including claim damage amount
Have you been declined rental coverage due to past claim losses?
*
Yes
No
Unsure
Rental Structure Information
Type of Rental Structure
*
Detached Home
Attached Townhome
Apartment Unit
In-law Unit
Farm Structure
Mobile/ Modular
Other
Year Built
Initial Date of Rental
*
Construction Type
Frame
Brick (all or partial)
Single ide
Double wide
Modular (on frame)
Modular (off frame/block foundation)
Type of Roofing
Shingle
Metal
Ceramic
Other
Siding Material
Vinyl
Wood
Brick/Mason
Other
Primary Heat Type
Electric
Gas
Heat Pump
Wood
Other
Wood Heat Type (if applicable)
Fireplace with insert
Fireplace
Wood burning stove
Central
Outside
Standalone
Other
Pool or hot tub onsite?
Not Applicable
In-ground
Above-ground
Basement
Not Applicable
Finished
Unfinished
Partial
Crawlspace
Coverage Options
Personal Property Contents (Value of all your possessions)
*
$50,000 or less
$50,00 - $100,000
$100,000 - $500,000
$500,00 or more
Liability Coverage Options
*
$100,000 (Minimum Required)
$200,000
$300,000
$400,000
$500,000
Other
Is Rental Coverage Required by Landlord?
*
Yes
No
Unsure
Current Renters Coverage Insurer
Who is your current renter insurance insurer?
Premium Amount?
Premium Paid?
Monthly
Quarterly
Annual
EFT/ E-Bill
Submit
Should be Empty: