MyPolicy.com - Personal Insurance - Renter's Insurance

Section One - Personal Information

Name:

Address:

City:

State:

Zip:

Country:

Telephone:

Fax:

E-Mail:

Date of Birth

Are you currently a Fitts Insurance customer? Yes No

Section Two - Home Description

Construction Type: Brick Frame

Year Built:

Please select all that apply to your apartment building:

Local smoke detectorLocal burglar alarm

Centrally monitored fire alarmCentrally monitored burglar alarm

Deadbolt locksFire extinguisher

Water leak alarm

Is your apartment within three (3) miles from a fire station? Yes No

Is your apartment within 500 feet from a fire hydrant? Yes No

Do you want replacement cost coverage on your personal property? Yes No

Are you a non-smoker? Yes No

If you own automobiles, would you be interested in combining the autos with the homeowner's policy for additional discounts? Yes No

How many automobiles do you own?

Which company insures them?

What liability limit do you have?

Section Three - Coverage Limits

Personal Property:$

Liability:$

Deductible:$

Select any additional coverage options:

Water backup

Earthquake

Identity theft expenses

Fungi, wet/dry rot, bacteria increased limits

List any items which you desire to have scheduled for an agreed amount, i.e. jewelry, furs, silverware:

Section Four - Claims History

How many years have you rented this apartment?

How many years have you been loss free?

Please describe all claims that you have incurred in the last ten (10) years:

Section Five - General Information

Have you had any property or liability claims or losses within the last six (6) years? If so, please explain:

Do you own any recreational vehicles such as boats, snowmobiles, golf carts, ATV's, motor homes,, etc? Yes No

Do you own any additional residences? Yes No

Do you have a wood stove? Yes No

Current policy expiration date:

Please list all animals owned:

Would you like a quote for an umbrella liability policy? Yes No

Limit desired:$

Do you conduct any business in the home? Yes No

If yes, do customers or vendors visit the home? Yes No

Do you require water back-up coverage? Yes No

Please indicate how you found our web site:

Prior Fitts Insurance Customer
Referral/Word of mouth

Please tell us who referred you:

Newspaper advertisement
Internet banner advertisement
Radio advertisement
Yellow Pages
Internet Search Engine

Google
Yahoo
Altavista
Webcrawler
Lycos
Other :

Other

Any additional comments: