Landlord Quote form

Contact Information

Name

Date of Birth

Preferred Quote Delivery: Phone
Email

Call-Back Phone Number

Email Address

Current Street Address (Not property to be insured)

Address

Address Line 2

State

ZIP

Information of Property to Be Insured

Address

Address Line 2

State

ZIP

Year Built

Building Material: Masonry
Siding
Stucco

Roof Material: Material Composition
Wood
Metal

Total Living Area (Square Feet)

Number of Stories

Number of Bathrooms

Garage

Foundation: Slab
Crawlspace
Basement

Type of Fireplace: Gas
Traditional
None

Type of Air Conditioning (check all that apply): Central
Window-Unit
Attic Fan
None
Other

Type of Heating (Check all that apply): Gas
Propane
Electric
Floor Furnace
Wall Furnace
Wood Stove
None
Other

Type of Electric: Circuit Breakers
Fuse Box

Type of Plumbing (Check all that apply): PVC
Copper
Cast Iron
Other

Year Roof Was Last Replaced

City Limits: Inside
Outside

Nearest Fire Hydrant: Under 1000 ft
Over 1000 ft

Nearest Responding Fire Department

Swimming Pool: Yes
No

Fence Around Pool: Yes
No

Diving Board: Yes
No

Slide: Yes
No

Dogs: Yes
No

If yes, how many and what breed(s)

Coverage Information

Coverage Requested for Dwelling

Coverage Requested for Landlord Furnishings: Yes
No

If yes, how much

Coverage Requested for Liability

Desired Deductible

An claims in the last 3 years at this property?: Yes
No

If yes, explain

Additional comments to your agent