Community Insurance Advisors :: Renter's Insurance

Section I - Contact Information

Name: *

Phone: *

Email: *

Confirm Email: *

Mailing Address *

Location Address: *

If you've lived at the above address for less than 3 years, please provide your prior address:

Section II - Optional Information

Following forms are optional, Please fill in if you would like to provide more information.

Current Insurance Information

Current Insurance Company (not agency)

Date Current Policy Expires:

/ /

Protection devices installed:

Smoke Detectors

Fire Extinguisher

Dead Bolts

Central Burglar / Fire Alarm

None

Property within City Limits?

Yes

If no ... how many miles to the nearest Fire District?

Distance in road miles to nearest fire department:

Distance to nearest fire hydrant (in feet):

Coverage Information

Value of your Personal Property:

Value of Unit (if greater than $1,000):

Loss Assessment Coverage ($1,000 improvement coverage included with basic policy):

Yes

Liability Coverage Limit

Desired Deductible:

High Valued Items (Item, Value)

These are high value items that need to be specifically identified, including jewelry, silverware, collectibles, furs, etc. Please list each item and

Heating... Year of Update:

Completion:

Electric... Year of Update:

Completion:

Plumbing... Year of Update:

Completion:

Roof... Year of Update:

Completion:

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Community Insurance Advisors - A Different Way of Doing Insurance
P:972-758-9300 | F:972-758-9355

Renter's Insurance

Renter's Insurance Application

Section I - Contact Information

Section II - Optional Information

Following forms are optional, Please fill in if you would like to provide more information.

Current Insurance Information

Coverage Information

High Valued Items (Item, Value)

TDI License Numbers

Community Insurance Advisors - A Different Way of Doing InsuranceP:972-758-9300 | F:972-758-9355

Renter's Insurance

Renter's Insurance Application

Section I - Contact Information

Section II - Optional Information

Following forms are optional, Please fill in if you would like to provide more information.

Current Insurance Information

Coverage Information

High Valued Items (Item, Value)

TDI License Numbers

Community Insurance Advisors - A Different Way of Doing Insurance
P:972-758-9300 | F:972-758-9355