Your Name:

Property Address:

Zip Code:

Phone Number:

Email Address:

Do you have insurance now?

Present insurance company:

My policy expires:

Yes

No

Have you reported any property claims within the past 3 years?

If yes, please give claim details here:

Yes

No

Number of Units:

Building:

Garage:

Roof Type:

Is the home equipped with at least one working smoke alarm?

Yes

No

Year Built:

Living Area Square Feet:

Do all exterior doors have dead-bolt type locks?

Yes

No

Does your home  have at least one fire extinguisher 2 1/2 pound or larger?

Yes

No

Exterior Walls:
enter percent of each as it applies to your rental

Home Enhancements
check the box if your rental has any of the following items

Interior Walls
check one

Cooling and Heating
check all that apply

Drywall

Burglar Alarm

Forced Air Conditioning and Heating

Stucco on Frame

Plaster

Fireplace

Swamp Cooler

Stucco on Masonry

Swimming Pool

Wall Heater with thermostat

Paint on Masonry

Central Vacuum

Wall Heater without thermostat

Trash Compactor

Wood Stove

Wood Siding

Solar Panels

Aluminum Siding

Other Enhancements:
list the quantity of each item if your rental has any of the following

Intercom System

Wood Shakes

Electric Air Cleaner

Sauna

Brick Veneer

Garage Door Opener

Jacuzzi/Hot-tub

Stained Glass Windows

Stone Veneer

Skylights

Wet bar

Additional Air Conditioner

Solid Brick

Total must equal 100%

Deductible

Liability Limit

Other Coverage Requested