Renters Insurance Quote Form
In order to give you a accurate quote please fill out this form completely.
Fields marked with * are required!
Your Information:
Your Name*
Property Address*
City, State, and Zip Code*
Phone #:
Fax #:
E-mail address:*
Your current age:
Any smokers?
Yes
No
Are you currently insured?
Yes
No
Current insurance company:
Policy expires:
Have you reported any property ins. claims?
Yes
No
If yes, please give claim details below:
Date of Loss:(mm/dd/yyyy) Cost of the Claim:($0,000,000.00) What Caused the Loss: (fire, wind, flood, dog, vandals, ect.) Additional Details: (Please be specific)
Your Home Information:
Number of Units:
One Unit
Two Units
Three Units
Four Units
5 to 6 Units
7 to 8 Units
Over 8 Units
Number of Stories:
One Story
Two Story
Three Story
Four Story
Over Four Stories
Split Level
Type of Garage:
One Car Attached
Two Car Attached
Three Car Attached
Detached Garage
Type of Roof:
Tile
Spanish Tile
Asphalt Composition
Wood Shake
Rock
Do all exterior doors have dead-bolt locks?
Does your home have at least one fire extinguisher 2½ pound or larger?
Is there a central station monitored burglar alarm system?
Is the home equipped with at least one working smoke detector?
Yes
No
Yes
No
Yes
No
Yes
No
What coverages do you desire?
Deductible:
250
500
1000
2500
Replacement Cost of Contents:
include
not wanted
Amount of Coverage Requested:
Please Select
$20,000.00
$25,000.00
$30,000.00
$35,000.00
$40,000.00
$45,000.00
$50,000.00
$75,000.00
$100,000.00
Enter Any Additional Remarks Here:
This page is provided as a service to you. It is not possible to bind any new coverage from this request. If you have NOT received your confirmation from us within 24 hours the same or next business day, please contact us.
NO COVERAGE IS CONSIDERED BOUND UNTIL YOU RECEIVE OUR CONFIRMATION
. Thank you for your understanding.
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Thank you for completing our form.
We welcome the opportunity to serve you.
Ramsey Insurance Agency
License #
0490642