Renter's Questionnaire

Desired Effective Date*

Agent*

Name*

Spouse Name

Occupation

Empl. Location city

Spouse Occupation

Spouse Location City

Subject Address

County

Home Phone #

Work #

Cell #

Social Security #

Spouse SS #

Date of Birth

Spouse Date of Birth

Claims in last 5 yrs
YesNo

Weather related?
YesNo

Theft
YesNo

Water
YesNo

Effective Date of new policy

Dogs
YesNo

Breed

Bite history
YesNo

Do you want coverage for Guns
YesNo

Jewelry
YesNo

Collections
YesNo

Description

Do you want extra coverage for water back up
YesNo

How did you hear about us?

Discounts

Do you currently have auto insurance?
YesNo

Who is your carrier?

Have you been insurance claim free for the last five years?
YesNo

Optional Coverage

WATER BACK-UP
Helps pay for water damage (such as cost to replace furniture) caused by backed up sewers, drains or sump pumps.
YesNo

SCHEDULED PERSONAL PROPERTY
Provides increased coverage to the renter’s policy and may increase the limits on specific, high-value items like jewelry, fur and art.

YesNo

OPEN PERIL CONTENTS
Broadens coverage to provide additional protection against loss to contents.
YesNo

IDENTITY THEFT EXPENSE
Covers expenses resulting from identity fraud, such as lost wages and loan application fees.
YesNo

PERSONAL INJURY LIABILITY COVERAGE
Covers claims such as libel, slander, invasion of privacy, false arrest, humiliation or defamation of character.
YesNo

ELECTRONIC DATA RECOVERY
Covers recovery of lost data, like family photos, videos and music, from computers in the event of a covered loss.
YesNo

PERSONAL PROPERTY REPLACEMENT COST REIMBURSEMENT
Provides replacement of the like, kind and quality of your contents, rather than the depreciated actual cash value, up to the limits of the policy.
YesNo

As part of the application process, we will order credit, motor vehicle and prior loss reports. This information will be used to evaluate your application. You may request a written statement describing our use of credit histories or insurance scores contained within our Credit Brochure.

Please confirm by typing your name in the blank below that you are authorized to initiate this insurance transaction and obtain consumer reports on behalf of yourself and your spouse, if applicable, or other individuals who will be insured under the policy.