Renters/Senior Living Quote

Agent Information

Agency Name *

Agency Code *

Agent First Name *

Agent Last Name *

Agent Email *

Agent Phone Number *

Applicant Information

Insured First Name & Last Name *

Entity Type *

Please provide description and name on Other *

Name of Corporation, Partnership, LLC or Trust

Location Address *

Apt, suite, etc.

Country

City

State

Zip code

Is mailing address different than the location address? *

Yes

Mailing Address *

Country

City

State

Zip code

Applicant's Email Address *

Applicant Phone *

Requested Effective Date *

Coverages

Personal Property Limit *

Coverage C

Loss of Use Limit

Coverage D

Personal Liability Limit

Coverage E

Medical Payment Limit

Coverage F

Occupancy *

Deductible *

Protection Class *

Optional coverage for renters *

Protection Systems

None

Central Station Burglar

Central Station Fire

Automatic Sprinkler System in 100% of building

Check all that apply

Losses

Have there been any losses/claims in the past three years? *

Yes

1. Coverage Type *

Property

Liability

1. Date of Loss *

1. Description of Loss *

1. Amount Paid *

1. Amount Reserved *

1. Status *

Open

Closed

2. Add another claim? *

Yes

2. Coverage Type *

Property

Liability

2. Date of Loss *

2. Description of Loss *

2. Amount Paid *

2. Amount Reserved *

2. Status *

Open

Closed

3. Add another claim? *

Yes

3. Coverage Type *

Property

Liability

3. Date of Loss *

3. Description of Loss *

3. Amount Paid *

3. Amount Reserved *

3. Status *

Open

Closed

Eligibility Criteria

Is any member of the household a federal or state political figure, professional athlete or coach, music or television entertainer or CEO of a Fortune 500 company? *

Yes

Does the applicant live in a mobile home? *

Yes

Is there a business exposure of any kind at this location? *

Yes

Are there any wood burning stoves? *

Yes

Is this location a boarding or rooming house, corporate housing facility, group home or a nursing or dementia care facility? *

Yes

Is the applicant a student? (not applicable in DC) *

Yes

Is there a dog at this location with a bite history, trained as an attack, guard or fight dog, dogs with a history of injuring other dogs or linked or alleged to be one of the following breeds (either purebred or mixed): *

Yes

Akita; Alaskan Malamute; American Staffordshire Terrier; American Pit Bull Terrier, Stafford Bull Terriers, American Bulldogs, or American Bullies, all commonly known as Pit Bulls; Cane Corsos; Chow Chow; Doberman Pinscher; German Shepherd; Great Danes, Mastiffs; Presa Canario; Rottweiler; or Siberian Husky?

Additional Insured Information

1. Add Additional Insured/Landlord? *

Yes

1. Name *

First & Last

1. Relationship/Interest *

1. Address *

Apt, suite, etc.

Country

City

State

Zip code

1. Additional Insured or Landlord *

Additional Insured

Landlord

2. Add Additional Insured/Landlord? *

Yes

2. Name *

First & Last

2. Relationship/Interest *

2. Address *

Apt, suite, etc.

Country

City

State

Zip code

2. Additional Insured or Landlord *

Additional Insured

Landlord

3. Add Additional Insured/Landlord? *

Yes

3. Name *

First & Last

3. Relationship/Interest *

3. Address *

Apt, suite, etc.

Country

City

State

Zip code

3. Additional Insured or Landlord *

Additional Insured

Landlord

Please provide supporting documentation you have:

Please provide any supporting documentation you may have:

Any Additional Questions or Comments?

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