Tenants Quote Questionnaire
Date
-
Month
-
Day
Year
Date
Time
Hour Minutes
AM
PM
AM/PM Option
Full Legal Name for all Individuals on lease
*
Named Lessee 1
Name - applicant 2
Name - applicant 3
Date of Birth
*
-
Month
-
Day
Year
Date
Date of Birth - applicant 2
-
Month
-
Day
Year
Date
Date of Birth - applicant 3
-
Month
-
Day
Year
Date
Phone Number
*
Format: (000) 000-0000.
Phone Number - applicant 2
Format: (000) 000-0000.
Phone Number - applicant 3
Format: (000) 000-0000.
Email
example@example.com
Email - applicant 2
example@example.com
Email - applicant 3
example@example.com
Civic Address: (Including Unit #)
*
Address of property to be insured.
Mailing Address; Same as Civic?
Yes
No (Write below)
Occupation of all applicants:
Applicant 1
Occupation of applicant 2
Occupation of applicant 3
Date of Occupancy/Policy Start Date:
-
Month
-
Day
Year
Date
Home Style:
Apartment
Home
Tiny Home
Approximate Square footage;
Heating Type Primary:
Heating Type Secondary:
If oil, tank location;
inside
outside
Does tenant purchase oil/access tank?
yes
no
Roof Type:
Year Last Updated:
Distance to hydrant:
Distance to fire hall:
Is there a home-based business? (clients, equipment, and/or inventory)
Yes
No
Is there a pool on the property?
Yes
In-Ground
No
Above Ground
Is there a trampoline on the property?
Yes
No net
No
Netted
Have you been continuously insured for the last 3 years?
Yes
No
Have you had any claim or significant losses in the last 5 years?
No
Yes (Explain below)
Do you have any high value items that require insurance?
No
Yes (Explain below)
How much coverage are you looking for on your contents?
Basic ($25,000)
Other
Please include any other details that may be relevant; (special occupancy details, roommate information)
Where did you hear about Clare Mutual Insurance?
Can we offer you an auto quote?
Yes
No
If Yes, when is your expiry date?
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