Renters H04 Questionnaire
Use this form to request a renter's quote. Please complete all of the information.
Please fill in all fields marked with a *
	First Name	*
	Middle Name
	Last Name	*
	Legal Owner	*
	Home Phone
	Work Phone
	Date of Birth
	Requested Effective Date
	Property Street	*
	Property City	*
	Property State	*
	Property Zipcode	*
	Legal Property Description	*
	How long at this address
	Mailing Street
	Mailing City
	Mailing Zipcode
	Work Street
	Work City
	Work Zipcode
	Employer or note if self employed
	Employment Type
	Years with employer
	Business Description
	Credit History
	Has the applicant filed for bankruptcy in the last 7 years	yes no
	Has dwelling been uninsured for more than 30 days immediately prior to the requested effective date	yes no
	Has the applicant had any credit account placed in collections in the last 3 years	yes no
	Certificate of Insurance for ESCROW Closing required	yes no
	Personal Property Value to be Insured
	Zipcode
	Year building was built
	Number of units in building
	Is there an HOA	yes no
	Construction Type
	Roof Type
	Heating Source
	Distance to fire hyrant and station	1000 ft or less to hydrant & 5 mi or less to station Over 1000 ft to hydrant & 5 mi or less to station.
	Distance to fire station	Between 5 & 10 mi to station Over 10 miles to station
	Located in Brush Hazard Area
	Smoke Alarms Installed
	Fire Extinguishers
	Deadbolt locks on main doors
	Theft Alarm Type	None Local Station Central
	Fire Alarm Type	None Local Station Central
	Limits of Liability requested
	Supplementary Medical
	Deductible Requested
	Loss of Use Coverage amount optional
	Contents coverage at Replacement Cost
	Number of Years Prior Insurance
	Date of Loss if any prior losses
	Number of Losses
	Payment Option Requested	Full Pay Installment
	Fax or email of where to send the quote