FOR INDIVIDUALS

Renter or Condo Insurance Assessment



How did you hear about us?

If referred by a friend, by whom were you referred?

Member of the Following Group or Association:

General Information


*Name:

Premises Address

*City:

*Zip:

*Email:

Apartment Number:

*State:

Fax:

*Phone:

Dwelling Details


Year Built (Approximately):

* Do you own the condo or apartment?
YesNo

Year Roof Updated:

Year Wiring Updated:

Year Heating Updated:

Year Plumbing Updated:

 
FullPartial

 
FullPartial

 
FullPartial

 
FullPartial

* What amount of personal property do you need to insure? (Minimum $20,000):

Check all of the following functional protective devices in your residence:

 

Do you have any of the following supplemental heating devices:
FireplaceWood Burning StoveGas Fireplace

Do you have any pets on the premises? (If yes, what breeds?)

* Do you have a trampoline on the premises?
YesNo

Is the house located within 1,000 feet of a fire hydrant and 5 miles of a fire station?
YesNo

* Have you had any claims in the last 5 years?
YesNo

If yes, please explain:

Do you need to itemize or schedule any personal property? (Insurance carriers limit coverage on jewelry, watches, furs, silverware, antiques, fine arts, guns and other items unless scheduled.)
YesNo

If yes, please explain:

*Preferred Deductible?:

Have you had a bankruptcy, repossession or foreclosure in the last 5 years?
YesNo

Do you want earthquake coverage on this home?
YesNo

Would you also like to receive a flood quote on this home?
YesNo

If yes, how much contents coverage would you like to include?

Does your home have a basement?
YesNo

Is the bank or landlord requiring this insurance for your loan?
YesNo

Have you had any flood damage at your residence?
YesNo

Additional Comments:

*How would you like to receive your quote?

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