Insurance Tenant Application

INSURANCE TENANT APPLICATION

Applicant Information

Applicant Name:

Date of Birth: Phone:

Policy Details Requested

Policy Type (select all that apply): HO-4 (Renters) Contents Only Liability Only

Deductible: Estimated Annual Premium:

Policy Period Requested: From to

Coverages and Options

Personal Property Coverage
Personal Liability
Medical Payments to Others
Loss of Use / Additional Living Expense
Loss Assessment Coverage (as applicable)

Prior Losses and Claims History

Have you had any property or liability claims in the past 5 years? Yes No

Additional Interest / Beneficiary

Name of Additional Insured / Loss Payee / Beneficiary (if any):

Exclusions and Important Notices

The insurer's policy will contain exclusions including, but not limited to: loss resulting from wear and tear, intentional acts, earthquake and flood (unless specific coverage is purchased), loss of business income unrelated to covered perils, damage from pests, and losses arising from illegal activity. Coverage for certain high-value items, motorized vehicles, watercraft and property used for business may be limited or excluded unless specifically scheduled.

I acknowledge that I have read and understand that standard renters policies contain exclusions and limit amounts for certain classes of property and perils. I further acknowledge that additional endorsements or separate policies may be required for full protection.

Applicant acknowledges receipt and review of the summary of exclusions and understands that coverage is subject to policy terms, conditions and endorsements.

Declarations and Certification

By signing this application I certify that the statements and answers provided herein are true, complete and correctly recorded to the best of my knowledge. I understand that this application becomes part of the policy and that false, misleading, omitted or incomplete information may be grounds for denial of coverage or rescission of the policy in whole or in part.

I authorize the insurer and its representatives to make inquiries and obtain information from public records, previous insurers, and other sources to verify or supplement the information provided. I understand that coverage will not be effective until the insurer accepts this application and issues a policy or binder, and that any acceptance may be subject to additional underwriting conditions.

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