Insurance Rental Application

INSURANCE RENTAL APPLICATION

Applicant / Insured Information

Date of birth:    Primary phone:

Occupation:    Driver's license / ID #:

Rental Property Details

Landlord / Property manager:    Contact:

Lease start date:    Lease end date:

Monthly rent: $    Security deposit: $    Number of occupants:

Pets on premises: Yes No

Policy Selection and Coverage

Policy type requested: Renters Liability-only Combined (personal property + liability)

Desired personal property limit: $    Liability limit: $

Deductible: $    Estimated annual premium: $

Policy period requested: From to

Coverage Options (select all that apply)

Personal property coverage    Loss of use / Additional living expenses    Medical payments to others

Identity theft expense coverage    Replacement cost for personal property

Optional & High-Value Coverages

Earthquake endorsement    Flood endorsement    Increased liability limit

Exclusions & Important Notices

Applicant acknowledges that standard policies exclude coverage for loss or damage caused by wear and tear, intentional acts, routine maintenance defects, war, nuclear hazard, and certain flood and earthquake losses unless an endorsement is purchased. Coverage for business property, motor vehicles, and animals is limited or excluded unless specifically endorsed. Applicant affirms they have read and understand these exclusions and that coverage will be subject to policy terms, conditions and limits.

Applicant initials to acknowledge receipt of exclusion summary:

Beneficiary Designation (for policy proceeds where applicable)

Relationship:    Allocation percentage: %

Declarations, Authorizations & Certification

By signing below, Applicant certifies that all statements and representations made in this application are true and complete to the best of Applicant’s knowledge. Applicant authorizes the insurer and its agents to obtain loss history, claims, credit-related information, and other underwriting data necessary to evaluate coverage. Applicant understands that material misrepresentation or omission may render any policy voidable or subject to premium adjustment.

Applicant consents to electronic correspondence concerning underwriting and policy administration. Applicant further authorizes the insurer to share policy and claims information with the landlord/property manager to the extent necessary to manage the policy and investigate claims.

Fraud warning: Any person who knowingly presents false information in an application for insurance may be guilty of insurance fraud under applicable law and may be subject to civil or criminal penalties.

Applicant acknowledges receipt of a copy of this application and agrees that this form shall be the basis of any policy issued. Applicant agrees to promptly notify the insurer of any change in material facts prior to policy inception.

Authorization to obtain report(s): I authorize the insurer to obtain underwriting and claims reports as permitted by law.

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