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Tenants Online Quote - HO-4

Agent Information:
Agent Name:
Agency Name:
Agent Email:	(A copy of the quote will be sent to this address)
Agent Phone:

Insured Information:
Insured Name:
Date of Birth:	//
Dwelling Address:
Dwelling City:
Dwelling State:
Dwelling Zip Code:

Dwelling:
Protection Class:*
	* If you do not choose a protection class, your quote is not valid and cannot be honored by Commonwealth Underwriters.
Year Built:
Is Dwelling in Good Condition?
Does Dwelling Have any Existing Damage?
Is Dwelling Undergoing any Renovation or Construction?
Type of Construction:

Applicant:
Please choose one of the following to describe insured's credit history:
Has the Applicant had any Conviction of Arson or Fraud Related to any loss on Property or Insurance?
Has there been a Bankruptcy Within the Last Year?
Has there been a Repossession in the last 3 years?
Any past due Child Support?

Insurance History:
Has there been any Prior Insurance on this Account?
Please input name of Prior Carrier:
Expiration Date of Previous/Current Insurance?:
Was Policy Terminated at Companies' Request?
Has there been a Lapse of Coverage over 30 Days?
What was the Reason for Termination?

Loss History:

Any Open Claims?
Number of Losses in the Last Three Years:
	If none, enter 0

	Date	Type of Loss	Details	Amount Paid
1)				$
2)				$
3)				$

Coverages:
Value of Contents?*	$
	$20,000 minimum value is included with the policy. Increase value if more coverage is required.
Limit of Liability:	$100,000 Included
Increased Cov. D?:
	Coverage D defaults to 10% of the Value of Contents.

Optional Coverages:
Replacement Cost Personal Property

Additional Comments
Any Additional Comments:

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For higher limits or coverage options not listed, please contact Adam Norman, Ext 113.

Any questions or problems with the form? Please contact Adam Norman

Only Commonwealth Underwriters, Ltd. has binding authority. Coverage will not be bound until application has been received, reviewed, and accepted by Commonwealth Underwriters, Ltd.

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Last modified 2010-11-17