Renter’s Insurance Application
Applicant Information
Name _____________________________________________________________________________
Date of Birth ________________________________________________________________________
SSN _______________________________________________________________________________
Email Address _______________________________________________________________________
Are you retired? _____________________________________________________________________
Dwelling Information
What type of dwelling are you renting?
Apartment Duplex Dormitory
Condominium Single-Family Home
Address of Residence _________________________________________________________________
City ____________________________________________ State _______ Zip Code _____________
Coverage Information
Yes No
Do you live with anyone? (Excluding children under 21)
Does your lease contract require all residents at the property to carry
renter’s insurance?
Have you or other residents of your household had any property insurance
claims or losses in the past 7 years?
Do you conduct any business, including home daycare, on the premises?
Do you have an animal that is vicious or attack trained, or that has previously
bitten or injured anyone?
Is a swimming pool located on the premises ?
Is there a skateboard ramp/bike ramp/trampoline on the premises?
What date would you like coverage to begin? ______________________________________________
How many years have you had continuous property insurance? _______________________________
Please list reason for applying for new insurance. __________________________________________
How much personal property coverage do you need? _______________________________________
(Personal property coverage includes all items in your home, including clothes,
furniture, appliances, linens, cleaning supplies, electronics, books, and so on.)
What type of animal(s) do you own? ____________________________________________________
Renter’s Insurance Claim Form
Insurance Policyholder Information
Name _____________________________________________________________________________
Insured Address _____________________________________________________________________
City ____________________________________________ State _______ Zip Code _____________
Phone Number ______________________________________________________________________
Email address _______________________________________________________________________
Claim Information
What date did the loss take place? ______________________________________________________
Loss type (e.g. fire, theft)
How severe was the damage? (e.g. minor, moderate, severe, unknown)
Do you have evidence of the loss? If so, what? (e.g. police report, photographs, witnesses)
Describe the loss. Include a description of what happened and a list of damages to property
and/or injuries to people.
What is the estimated cost of damage? __________________________________________________