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Renters Insurance Application Form
Renters Insurance Application Form
First Name
Last Name
Date of Birth
Phone Number
Email Address
Current Address (where you are renting) :
Street
Apt/Unit
City
State: GA
ZIP
How long have you lived at this address?
Under 6 months
6–12 months
1–3 years
3+ years
Do you rent an:
Apartment
Condo
Townhome
Single-family home
Room in someone’s home
Landlord or Apartment Complex Name (if applicable):
How much personal property coverage do you want?
$10,000
$20,000
$30,000
$40,000
$50,000
$75,000
$100,000
Other: _________
Liability Coverage Needed:
$100,000
$300,000
$500,000
Loss of Use / Additional Living Expense Coverage:
Standard
Increase amount: __________
Deductible Preference:
$250
$500
$1,000
Is this your primary residence?
Yes
No
List all household members who live with you:
Yes
No
List all household members who live with you:
- Select -
Name
Date of Birth
Relationship
Any pets?
No
Yes (list breed & weight): _____________________
Any aggressive-breed dogs?
No
Yes — carrier guidelines may apply
Do you smoke or vape inside the home?
Yes
No
Type of building construction:
Wood
Brick
Concrete
Mixed
Does your unit have the following?
Smoke detectors
Fire extinguisher
Sprinkler system
Gated access
Security patrol
Deadbolt locks
Alarm system (monitored)
Pets restricted building
Year the building was built (estimate if unsure):
Do you have any high-value items that need special coverage?
Jewelry
Watches
Firearms
Artwork
Collectibles
Designer handbags
Musical instruments
Electronics over $2,500
No special items
If YES, list each item and its value: (Some carriers require receipts or appraisals for items over $1,000)
Any renters or homeowners insurance claims in the last 3 years?
No
Yes (select all):
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