K V Agency - Renters Insurance Quote Form

Personal Information
Full Name:*
Date of Birth:*

MonthDayYear
Date
Social Security Number:*
Phone Number:*
Email Address:*
example@example.com
Current Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Property Information
Rental Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Dwelling:*

ApartmentHouseCondoOther
Number of Rooms:*
Square Footage:*
Year Built:*
Smoke Detectors:*

YesNo
Fire Extinguishers:*

YesNo
Security System:*

YesNo
Type:*
Insurance Coverage
Desired Coverage Start Date:*

MonthDayYear
Date
Coverage Amount: $*
Liability Coverage Amount: $*
Deductible Amount: $*
Additional Riders: (Jewelry, Electronics, etc.)*
Previous Insurance Information
Have you had renters’ insurance before?*

YESNO
If yes, please provide the following details:
Insurance Company Name:*
Policy Number:*
Coverage Dates From:*

MonthDayYear
Date
Coverage Dates To:*

MonthDayYear
Date
Reason for Switching:*
Applicant Signature
I hereby certify that all the information provided in this application is true and correct to the best of my knowledge. I understand that providing false information may result in the denial of coverage or cancellation of the policy.
Applicant Signature:*

Clear
Date:*

MonthDayYear
Date
Agent Use Only
Agent Name:*
Agency:*
Contact Number:*
Email Address:*
example@example.com
Policy Number:*
Coverage Start Date:*

MonthDayYear
Date
Terms and Conditions
By signing this application, you agree to the terms and conditions of the renter’s insurance policy provided by our company. This includes, but is not limited to, the following:

• You must inform us of any changes to your living situation or property that may affect your coverage.
• You must notify us immediately in the event of a claim.
• Coverage is subject to the terms and limitations outlined in your policy documentation.

Please review your policy documentation carefully and contact us if you have any questions or concerns regarding your coverage.
Privacy Policy
We are committed to protecting your privacy. All personal information provided in this application will be used solely for the purpose of processing your renter’s insurance application and will be kept confidential in accordance with our privacy policy.
For more details, please refer to our full privacy policy available on our website or contact our customer service department.
Should be Empty:

Personal Information

Property Information

Insurance Coverage

Previous Insurance Information

Applicant Signature

Agent Use Only

Terms and Conditions

Privacy Policy