Renters & Condominium Quote Request

For Residents of Illinois Only

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Please make an effort to complete to the best of your ability all
the areas that you can, especially the required areas.

Full Name
Address
City
County
State Zip
Work Phone
Home Phone
E-Mail Address
Is this a Quote For Renters: Yes  No
Is this a Quote For for a Condo: Yes  No
Are You Currently Insured?  Yes  No
With what specific company?
How long with this company? Years.

Please indicate any insurance concerns you might have.

Basic Information Regarding Your Home;

Number of Units in Your Building:


Do You Reside In The Structure:
Yes No

Year built:


Fire protection class:
(if known)

Distance To Fire Hydrant:
(in feet)

Distance To Nearest Responding Fire Department:
(in miles)

Smoke Alarms:          
Yes No

Fire Extinguisher:     
Yes No

Central Station Alarm: 
Yes No (This is the type of alarm that alerts a service)

Dead Bolts:            
Yes No

Inside City Limits:    
Yes No

Construction Material  


Roof Type:             


Liability Limits:
(How much do you want to insure your property for)

Current Content Value of Residence:
(Your current coverage amount)

Deductible:

General Information

 

Have you had any claims or losses within the last 3 years?
If so, please explain:

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I Understand that this service merely provides a proposal request and is not a Policy of Insurance, Application or Offer to Insure on behalf of any Insurance Company, Agency or Agent. Individual companies reserve the right to accept, reject or modify a proposal after investigation and review.

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