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Landlord's Insurance
Quote Request Form
One Simple Form - takes only 2-3 Minutes!

Your Name (First and Last):
Business Name:
Policyholder's Date of Birth:
Mailing Address:
(again for accuracy):
Property Address:
Property in what COUNTY?:
Dwelling Information
Year Building Built:
Building Square footage:
Select # of Stories:
Select Foundation Type:
Select Garage Type:
Basement % Finished:
Select # of Units:
Select Electric Type:
Is Property currently vacant? No Yes
If yes to vacant, when will it be occupied?
Property in city limits? No Yes
Is home used for college housing? No Yes
Is property a Condominium? No Yes
Is property a Vacation Rental? No Yes
Is there a woodstove?
Is there a pool over 2.5 feet in depth? No Yes
Is there a trampoline? No Yes
Is there a dog on premises? No Yes
If yes to dog, what breed is it?
Does dog have bite history of ANY kind?
If yes, describe
Prior claims? No Yes
If prior claims, describe in detail:
Building Coverage Amount: $
Separate Structures Coverage Amount: $
Landlord's Contents Coverage Amount: $
Liability Coverage Amount:
Policy Deductible:
$5000 Water Backup of Sewer and Drain Coverage? No Yes

Other Coverage/Remarks
(describe any additional information
you feel may be helpful in determining
your quote or coverage, etc.):

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