Renters Insurance Application

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(800) 858-1315

App - Renters Insurance

Insured Information

Name

First Last

Date of Birth

MM slash DD slash YYYY

Phone

Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Policy Effective Date

MM slash DD slash YYYY

Move-In Date

MM slash DD slash YYYY

FAIR Plan or Equivalent Policy?

Yes

No

Any Losses?

Yes

No

Insurance Limits

Personal Property Limit:

Loss of Use Limit:

Personal Liability Limit(Required)

Medical Payments Limit:

$1,000

$2,500

$5,000

Deductible

$250

$500

$1,000

$2,500

Property Information

Protection Systems

Central Station Burglar

Central Station Fire

Automatic Sprinkler System

Number of Bedrooms

Number of Bathrooms

Square Feet

Number of Occupants

Monthly Rent

Construction Type

Residence Type

Number of Units in Building

Loss History

Coverage Type	Date of Loss	Amount Paid	Actions

There are no Losses.

Maximum number of losses reached.

Eligibility Questions

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

No

Does the applicant live in a mobile home?

Yes

No

Is there a business operating at the residence?

Yes

No

Are there any wood burning stoves?

Yes

No

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

Yes

No

Is the applicant a student?

Yes

No

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): 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?

Yes

No

License 0E63493

Coverage Type

Property

Liability

Date of Loss

MM slash DD slash YYYY

Description of Loss

Amount Paid

Status

Opened

Closed