RENTERS QUOTE FORM

Date:

Referred by:

Name:

Address:

City:          State:      Zip:

Phone:     Home            Work

E-mail address

Present/Prior CarrierIs policy currently in force? YesNo

If yes, expiration date:

Type of dwelling: Frame  Masonry  Mobile   

Age of building:  Number of families:

Smoke detectors: YesNo    Fire extinguishers: YesNo    Deadbolts: YesNo

Does anyone in the household smoke? YesNo

Any prior losses? YesNo        Please explain

Any incidental business? YesNo      Please explain:

Any scheduled items? YesNo          Please explain:

Do you currently use a waterbed? YesNo 

Is there a woodstove? YesNo 

Amount of insurance on contents:

Liability limits:            Deductible:

Distance to fire hydrant: Less than 1000 feet    Over 1000 feet

Distance to full time fire station: Less than 5 miles    Over 5 miles

Do you own any dogs? Yes    No         Age:    Breed:

Please use this space below for any additional information that you would like us to have..