RENTAL PROPERTY QUOTE

PERSONAL INFORMATION

        First Name                                   
        Last Name                                    
        Phone Number                             
        Fax Number                              
        E-Mail Address                             
        Who Referred You to Our Site?  
 

PROPERTY INFORMATION

        Property Address                          
        Property City                                 
        Property Zip Code                         
- Single Family Duplex Triplex Fourplex Condo Townhouse                                   Dwelling Type                                

- Homeowners Renters Condominium                                   Type of Insurance requested
        Number of Bedrooms                   
        Number of Bathrooms                  
        Number of Fireplaces                   
- 1 Car Attached 2 Car Attached 3 Car Attached 1 Car Detached 2 Car Detached 3 Car Detached 1 Car Carport 2 Car Carport 3 Car Carport                                Garage Description                       
        Year Built                                        
        Date You Purchased Your Home
- 1 2 3                                                      How Many Stories                         
        Ground Floor Square Footage     
        Total Square Footage                   
- Wood Frame Steel Frame Masonry Log Adobe                                    Construction Type

- Slab Built on Pillars-Piers Raised                           Foundation Type

- Gas Electric Other                                             Energy Source

- None Partial Full                                               Interior Automatic Fire Sprinklers
- None Local Central                                              Theft Alarm                                      
- None Local Central                                              Fire Alarm                         
- Asphalt Shingle/Composition Clay/Slate Tile Concrete Tile Tar and Gravel Wood Shake/Shingle Rock Corrugated Steel             Roof Type                                        
yes   no                                      Roof Updated;            Year:                                        
yes   no                                      Does the Dwelling Have a Pool   
yes   no                                      If Pool, Is it Fenced                       
yes   no                                      If Pool, Is There a Diving Board  
yes   no                                      If Pool, Is There a Slide                                           
yes   no                                      Is Dwelling in the Brush              
yes   no                                      Smoke Alarm                                  
yes   no                                      Fire Extinguisher                           
yes   no                                      Deadbolts                                        
yes   no                                      Electrical Updated;    Year:                           
yes   no                                      Circuit Breakers                             
yes   no                                      Copper Wiring

yes   no                                      Central Heating, Air Conditioning?
yes   no                                      Heating/Air Conditioning, Thermostatically Controlled

yes   no                                      Plumbing Updated;    Year:                            
yes   no                                      Copper Plumbing                            
 

MISCELLANEOUS INFORMATION

                                        
         Current Insurance Company        
         Exp. Date of Current Policy 

         Current Premium          
yes   no                                      Any Dogs on the Property

            
If Yes, Number & the Breed of Each Dog:
 

- None 1 2 3 4 5                                                 Losses or Claims in the last 5 years

 
If Yes, Date, Amount Paid & Description of Each Loss or Claim
 

- Yes No                                                     Seasonal Rental?

- 1 2 3 4 5 6 7 8 9 10                                                       Number of residents

            Relation of tenants to owner


COVERAGE INFORMATION

            Dwelling Amount (Coverage A)  
            Other Structures (Coverage B)   
            Personal Property (Coverage C) 
            Loss of Use (Coverage D)            
- 300,000 500,000 1,000,000                                              Premise Liability (Coverage E)    
- 500 1000 2500 5000 10,000                                                  Policy Deductible                            
- No Earthquake Coverage 10% Deductible 15% Deductible 20% Deductible                     Earthquake deductible, if selected  

Questions or Comments to help the Agent:

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