First Last Name

Birth Date

Second Adult Occupant Name

Birth Date

Marital Status

Single Married Divorced MarriedbutSeparated

Address to be Insured

Apartment # or Unit #

City

 GEORGIA

ZIP

County

Phone Number

E-Mail Address

Fire Sprinkler system in unit?

Yes

No

Dead Bolt Lock

Yes

No

Smoke Detector

Yes

No

Fire Extinguisher

Yes

No

Monitored Security System

Yes

No

Gated Community

Yes

No

Community 24 hour Security

Yes

No

Are you currently insured with “Renters”. “Condo” or “home” insurance? (less than 30 day lapse)

No Prior Coverage Renters Ins Condo Ins Home Ins

Current Insurance Company Name

Any Claims in the last 3 years?

No Claims 1 Claim 2 Claims

Define losses if any

Property Coverage  Limit

15,000 minimum 20,000 25,000 30,000 35,000 40,000 45,000 50,000 55,000 60,000 65,000 70,000 75,000 80,000 85,000 90,000 95,000 100,000 110,000 120,000 130,000 140,000 150,000

Liability Protection  Level

100,000 200,000 $10.00 more 300,000 $20.00 more

Medical Coverage Level

1,000 2,500 $5.00 more 5,000 $9.00 more

Complex Name or Name of Property Management Co.

Leasing Agent Name

Phone Number

Comments

As part of the application process, we may collect personal information from persons other than you or other individuals proposed for coverage, including credit reports and loss information reports. This information, as well as other personal or privileged information subsequently collected by us, may in certain circumstances be disclosed to third parties without your authorization. You have a right of access and correction with respect to all personal information we collect. If you would like more detailed information in writing about our information collection practices, please let us know.

NOTE: In regard to the statement above, we are required to post this as a process of obtaining Loss Information History and final quoting criteria.  Submitting this form approves the collection of data.  We have not asked for and do not require a social security number in this process