Rental Property Information
Rental Address *
City *
State *
Select State
Ohio
Pennsylvania
Michigan
Indiana
West Virginia
Kentucky
ZIP Code *
Type of Residence *
Select Type
Apartment
Single Family House
Townhouse
Duplex
Rented Condo
Mobile Home
Room in House/Apt
Studio Apartment
Loft
Lease Start Date *
Lease End Date
Leave blank for month-to-month
Monthly Rent Amount *
Approximate Square Footage
Number of Bedrooms *
Select
Studio
1 Bedroom
2 Bedrooms
3 Bedrooms
4 Bedrooms
5+ Bedrooms
Number of Bathrooms *
Select
1
1.5
2
2.5
3+
Which Floor? *
Select
Basement
1st Floor
2nd Floor
3rd Floor
4th Floor or Higher
Not Applicable
Landlord Information
Landlord/Property Manager Name *
Landlord Phone Number
Minimum Liability Required by Lease
Not Required/Not Sure
$100,000
$300,000
$500,000
$1,000,000
Occupants
Number of People Living in Unit *
Select
1 (Just Me)
2
3
4
5
6 or more
Do you have roommates? *
Select
No
Yes, Related (Family)
Yes, Unrelated
Safety Features
Coverage Options
Personal Property Coverage *
Select Amount
$10,000
$15,000
$20,000
$25,000
$30,000
$40,000
$50,000
$75,000
$100,000
Covers your belongings if stolen or damaged
Personal Liability *
Select Amount
$100,000
$300,000
$500,000
$1,000,000
Protects you if someone is injured
Medical Payments to Others
Select Amount
$1,000
$2,500
$5,000
Covers medical bills for guests
Deductible *
Select Amount
$100
$250
$500
$1,000
Lower deductible = higher premium
Insurance History
Personal Information
First Name *
Last Name *
Email Address *
Phone Number *
Date of Birth *
Occupation
When do you need coverage to start? *
How did you hear about us?
Select
Landlord Referral
Friend/Family
Online Search
Social Media
Other
Special Requests or Questions