Renter Quote Information Form
Effective date
*
Renter Information
Name
*
Mailing address
*
City
*
State
*
Zip
*
Home phone
*
Work phone
*
Cell phone
Date of birth
*
Marital Status
*
Select
Single
Married
Divorced
Separated
Occupation
*
Co-applicant name
Co-applicant date of birth
Co-applicant occupation
Prospect Location Description:
Address (if different from above)
City
State
Zip
Distance to fire hydrant (ft)
*
Distance to fire station (miles)
*
Miscellaneous:
Trampoline
*
Select
Yes
No
Snowmobile/4-Wheeler
*
Select
Yes
No
Pets
*
Select
Yes
No
Breed
Jewelry to schedule
*
Select
Yes
No
Fine arts
*
Select
Yes
No
Business at home
*
Select
Yes
No
Filed for bankruptcy in last 5 years
*
Select
Yes
No
Losses
*
Select
Yes
No
If yes, explain.
Credits:
Deadbolt
*
Select
Yes
No
Sprinklers
*
Select
Yes
No
Smoke detectors
*
Select
Yes
No
Fire extinguishers
*
Select
Yes
No
Central burglar alarm
*
Select
Yes
No
Central fire alarm
*
Select
Yes
No
Multi policy
*
Select
Yes
No
Liability:
Liability limit (standard $300,000)
Contents limit ($)
Deductible (standard $500)
53 Loveton Circle, Suite 120 • Sparks, MD 21152
Phone • 1.800.926.8085 • 410.472.1620 • Fax • 410.472.1897
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