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  virginia independent insurance agency

RENTERS/TENANTS POLICY REQUEST FORM
Name:


Address:


City:


State:


Zip:


Home Phone:


Work Phone:


Email Address:


When and How do we contact you? (Home Phone, Work Phone, Email)

Do you live in an apartment building?

Yes   No

If yes, how many units are in the building?


Do you rent a house?

Yes   No

If yes, how many families live there?


What is the outside wall of the building constructed of?

 

Frame
 Masonry
 Aluminum/Vinyl Siding
Brick Veneer
Other, please explain

How much personal property (contents) coverage do you need?

$

Do you want replacement cost coverage?

Yes   No

Any pets? If yes, what kind?


How many?


Have you had any claims in the last five years?

Yes   No

If yes, please provide details:

Are you currently insured?

Yes   No

If yes, what company?


List All Other Residents Living With You And State Relationship
Resident Relationship To You
Any business activities conducted in your residence?

Yes   No

If yes, please provide details:

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