Landlord Insurance Form

* = Required Information

Personal Information

First Name *

Last Name *

Gender

Street

City *

State

Zip code *

Occupation

Date of Birth

Home Phone *

Business Phone *

Cellphone Number *

Best Number to Call

Marital Status *

Email Address *

Property Address

Street *

City *

State

Zip code

County

About your home

Number of units *

Living sq. footage

Year built

Number of levels *

Number of car garage *

car garage

Attached

Detached

Built-in

Number of bathrooms *

Number of firepalces *

Swimming pools

Yes

No

Heating

A/C

Yes

No

Construction type

Roof type

Roof age

Foundation

Exterior type

Coverage Limits

Liability requested *

Deductible *

Dwelling

Personal property

Loss of use

Discounts

Smoke detector *

Sprinkler coverage *

Auto insurance company *

Burglar alarm *

Type of alarm *

Non-smoker discount *

Insurance Information

Prior/current carrier

Number of claims (in last 3 years)

1. Type of claim

Amount of claim

2. Type of claim

Amount of claim

3. Type of claim

Amount of claim

Comments