Insurance Tenant Quote

INSURANCE TENANT QUOTE

Quote Date:    Quote No.:    Agent/Broker:

Applicant / Insured Information

Property Details (Rented Unit)

Number of residents at location:    Pets on premises: Yes No

Proposed Coverage

Personal Property Coverage - Limit: $    Basis: Replacement Cost Actual Cash Value

Personal Liability - Limit: $    Medical Payments to Others - Limit: $

Loss of Use (Additional Living Expense) - Limit: $    Deductible: $

Optional Endorsements

Earthquake coverage (+ premium): $

Flood coverage (+ premium): $

Scheduled Items (jewelry, electronics) - List separately and provide values below if selected.

Claims and Underwriting Information

Any claims or losses in the past 5 years? Yes No

Exclusions and Limitations

This quotation does not bind coverage. Any policy issued will contain exclusions including, but not limited to, loss or damage caused by:

- Wear and tear, gradual deterioration, insect or vermin damage.

- Intentional acts, fraudulent acts, or losses arising from criminal activity by the insured.

- Nuclear hazard, war, government action, and similar perils unless specifically endorsed.

- Flood and earthquake are excluded unless a corresponding endorsement is purchased.

Applicant acknowledges awareness of the principal exclusions above. Applicant initials to confirm:

Beneficiary Designation (for certain proceeds)

Beneficiary Name:

Relationship to Insured:    Allocation (%):

Premium Summary (Estimated)

Estimated Annual Premium: $    Policy Fee: $    Total Due at Binding: $

Payment frequency desired: Annual Monthly

Declarations and Authorization

The undersigned Applicant declares that all statements contained in this quotation request are true and complete to the best of their knowledge. Applicant understands that this document is a quotation only and does not constitute a binder of insurance. Coverage will only become effective upon issuance of a policy or binder by the insurer and receipt of the required premium or deposit.

Applicant understands that the insurer will rely on the accuracy of the information provided for underwriting and premium determination. Failure to disclose material facts or any material misrepresentation may result in denial of coverage or rescission of the policy. Applicant authorizes the insurer and its representatives to obtain and verify personal, credit, claims, and loss history information necessary to evaluate the application and administer any resulting policy.

This quotation is subject to underwriting review and may be modified or withdrawn at any time prior to binding. Any changes to coverage, limits, endorsements, or applicant information may alter the premium shown above.

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