Insurance Renters Application

INSURANCE RENTERS APPLICATION

APPLICANT / INSURED INFORMATION

Date of birth: Social Security – last 4 digits:

RESIDENCE & OCCUPANCY

Insured property address (if different from mailing):

Primary residence Second/seasonal residence Rented unit (tenant)

Number of occupants: Number of bedrooms:

POLICY DETAILS

Policy type: Renters insurance

Requested effective date: Policy term (start): (end):

Personal property coverage Replacement cost endorsement

Personal liability coverage Coverage amount: $

Deductible: $ Estimated annual premium: $

Payment plan: Annual Quarterly Monthly

PROPERTY SECURITY & RISK INFORMATION

Smoke detectors: Yes No Burglar alarm: Yes No

CONTENTS & HIGH-VALUE ITEMS

Do you own any items individually valued in excess of $2,500? Yes No

PRIOR INSURANCE & CLAIMS HISTORY

Any claims in the past 5 years? Yes No

ADDITIONAL COVERAGE OPTIONS

Loss of use / Additional living expense coverage Personal property off-premises coverage

Sewer or sump pump backup (optional endorsement) Flood coverage (available by separate policy)

EXCLUSIONS & LIMITATIONS

The policy generally excludes damage or loss caused by: flood, earth movement, routine wear and tear, intentional acts, nuclear hazard, and acts of war. Limits apply to certain categories such as jewelry, furs, and business property. Additional limitations and endorsements may be required for specified high-value items.

Initials:

BENEFICIARY DESIGNATION

Designate beneficiary for return of premium or any payable proceeds where applicable. Beneficiary designation is subject to policy terms.

REQUIRED DOCUMENTATION CHECKLIST

Copy of government-issued photo ID Proof of residency (lease or utility bill)

Personal property inventory (recommended) Appraisals/receipts for high-value items

DECLARATION, AUTHORIZATION & FRAUD WARNING

By signing below, I certify that the information provided in this application is true, complete and correct to the best of my knowledge. I understand that any material misrepresentation or omission may result in denial of coverage, rescission of the policy or adjustment of claim payments. I agree to notify the insurer promptly of any material change in risk.

I authorize the insurer and its representatives to make inquiries and inspections for the purposes of underwriting and claims handling, including verification of prior loss history and other relevant records. I consent to the release of information necessary to underwrite or service this policy to and from other insurers and consumer reporting agencies as permitted by law.

Fraud Warning: It is unlawful and a criminal offense to knowingly provide false, incomplete or misleading information for the purpose of defrauding the insurer. Such acts may result in criminal prosecution and civil penalties.

Sign Now