Page Insurance, Ltd
102 Boston Street
Guilford, CT 06437
(203) 453-5258
info@pageins.com
Landlord Insurance Quote Form
Where did you hear about Page Insurance?
Effective / Closing Date
-
Month
-
Day
Year
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TYPES OF INSURANCE REQUESTED
*
Rented Dwelling
Rented Condo
Vacant
Any insurance declined, cancelled or non-renewed in the last 3 years?
Yes
No
Provide the date and reason:
Has there been any lapse in coverage in the past year?
Yes
No
Provide the date and reason:
Number of claims in the last 5 years?
Are you the Building Owner or the Insurance Agent?
*
Building Owner
Condo Unit Owner
Insurance Agent
Entity Type
*
Sole Proprietorship
Limited Liability Company
Cooperative
Corporation
Partnership
S Corporation
If Limited Liability Company (LLC):
Single Member
Multiple Member
Name of Building Owner (if other than individual)
Your Name
*
First Name
Last Name
DOB
*
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Month
-
Day
Year
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Occupation
Marital Status
*
Please Select
Single
Married
Divorced
Widowed
Is there another Named Insured?
Yes
No
Spouse / Other Named Insured
First Name
Last Name
Spouse / Other DOB
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Month
-
Day
Year
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Occupation
Mailing Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
E-mail
Cell Phone Number
-
Area Code
Phone Number
What is the best day/time to get in touch with you?
Best Method to Contact
Phone
Email
Either
Current Company
Check box below if Location Addrss is the same as the mailing address
Location Address is the same as the mailing address
Location Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Do you have city water?
*
Yes
No
Is the house within 1,000 feet of a fire hydrant?
*
Yes
No
Protection Class (if known)
FOR UNDERWRITING USE
Build Quality
*
Average
Semi-Custom
Custom
Quote Requirements
Rows
Yes
No
Replacement Cost Calculated?
Assessors Field Card
Canceled/Non-Renewed/Declined Past (3) years?
Claims in the past (3) years?
Continuous Coverage for Past Year
If Yes, Explain:
CURRENT / PROPOSED
POLICY
LIMITS
Dwelling Limit
Other Structures
Personal Property
Loss of Use
Liability Limit
Please Select
300,000
500,000
1,000,000
Medical Payments
Number of Families
*
1
2
3
4
5
More than 5
Do you rent on a short term basis (weekly, monthly)?
Please Select
Yes
No
VACATION RENTAL
What length of time is the dwelling offered for rental?
Hourly
Daily
Weekly
Monthly
Annually
Other
What is the minimum number of nights rented per rental term?
What is the cost per night rental rate?
How many weeks per year is this property rented?
What purpose or use is the dwelling available for rent? (Check all that apply)
Residential
Corporate/Business
Photo/Film Shoot
Exhibit/Show
Party/Reception/Wedding
Meeting/Workshop/Training
Other
What is the maximum number of tenants and their guests allowed in the dwelling?
Is there a management company contracted for this rental? Enter Name, if any
If yes, what is their general liability limit?
If no management company, how are renters screened and who screens the renters?
Is the rental inspected after each rental?
Yes
No
If yes, who inspects the dwelling?
What is the minimum age for tenants?
Are there any employees (Maids, Groundskeepers, Caretakers, etc.)?
Yes
No
If yes, are they resident employees?
Are there any enclosed swimming pools or trampolines on the property?
Yes
No
Will there be any usage by the insured as a secondary or seasonal residence?
Yes
No
If rented, do you advertise on the any of the following?
AirBnb
VRBO
HipCamp
Other
Do your tenants have any dogs?
*
Yes
No
Other
Do your tenants have other animals or pets
*
Yes
No
Other
Do you have a wood stove?
*
Yes
No
Wood Stove Info
Rows
Yes
No
Prof Install
Inspected?
Cleaned Annually
Swimming Pool
*
Yes
No
Above or In-ground?
Above Ground
In Ground
Fence/DB/Slide?
Rows
Yes
No
Fenced
Diving Board
Slide
Do you have any of the following?
*
Rows
Yes
No
Do you have a trampoline?
If yes, does it have a net around it?
Do you have an underground Oil tank?
Do you rent to college students?
Do you conduct any business In the home?
Type of In-Home Business
Average # of Clients Daily
Do you have an alarm system?
*
Rows
Yes
No
CS Burglar
CS Fire
Local Smoke
Deadbolts
Fire Extinguishers
Are there any trees overhanging the house?
*
Yes
No
Is dwelling listed on an online home sharing website (such as AirBnB, VRBO,etc..)?
Yes
No
Is the property isolated?
Yes
No
Is the property a seasonal home?
Yes
No
Are roof mounted solar panels present?
Yes
No
Type of solar panels
Thermal (Heating Water)
Photovoltaic (Electricity)
Are there any adjacent frame dwellings within 20 feet of the risk?
Yes
No
Any business or day care conducted on premises?
Yes
No
Is the property occupied by undergraduate students?
Yes
No
BUILDING AND UPDATE INFORMATION
Year Built*
*
Square Feet*
Construction Quality
*
Builders Grade
Semi-Custom
Custom
Is the basement finished?
*
Yes
No
N/A
What percentage of the basement is finished?
Has the roof been updated ?
Yes
No
Original
Unknown
Year
Partial
Complete
Plan to replace roof?
Yes
No
If yes, when?
Electrical Updates
*
Yes
No
Original
Unknown
Year
Partial
Complete
# Amps
*
60
100
200
Circuit Protection
*
Rows
Yes
No
Circuit Breakers
Any fuses?
Knob/Tube Wiring
Plumbing Updates
*
Yes
No
Original
Unknown
Year
Heating Updates
*
Yes
No
Original
Unknown
Year
Type of Heat
Oil
Gas
Electric
Propane
Type of updates
Location of Oil Tank:
*
Last Service Date
*
/
Month
/
Day
Year
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Do you have a mortgage?
*
Yes
No
Mortgagee Information
Contact Information @ Bank
If New Purchase, do they require payment in full for the first year?
Yes
No
Who will be billed on renewal?
Bank
Insured
Name of Person Submitting Form
*
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