Contact Information
Name:
Mail Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Fax:
Email Address:
What is your preferred form
of contact to receive your quote? Home Phone Work Phone Fax Email Mail If by phone, best time
to call:
I Would Like A Competitive
Quote
Based on my
CURRENT POLICY which expires: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Insurance Carrier:
For a NEW RENTAL,
date: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Desired
Coverages
E. Personal Liability: $100,000 $300,000 $500,000
C. Personal Property ($): 15,000 20,000 25,000
30,000 35,000 40,000
50,000 75,000 100,000 15,000
minimum
F. Medical Payments:
$1,000 $2,000
$3,000 $5,000 $10,000 $25,000
Deductible Amounts: $250 $500 $1000
Personal Umbrella
Liability: None $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000
How many vehicles?
0 1 2 3 4 5
Number of Apt. Claims in the
Last 3 Years (please describe--loss type,
date & amount paid):
Information
About Your Apartment
Location of
Apartment: (if different
from that address above)
Year Built:
Total Units in
Apartment:
What floor is apt? Basement First Second or
higher
Construction:
Frame Brick Veneer Brick Masonry
Fire
resistive
Non-Smokers: Yes
No
Alarm Systems: Central Burglar Central Fire
Monitored by Central
Station? Yes No
Safety Systems: Smoke Detector Deadbolts Fire
Extinguishers Sprinklers
Account Credit
Eligibility
What insurance
company writes your MA auto insurance? Renewal
Date: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Is application complete and ready to
submit? Yes