Renters/Condo Insurance Quote Form

General Information

Name:

Address:

City, state and zip:

 ,    

County:

Date of Birth:

Email:

Daytime phone:

 ( ) -

FAX:

 ( ) -

Do you currently attend a Mennonite, Brethren in Christ or Missionary Church? Yes No

Current Insurance Company (not agency):

Company name:

Policy exp. date (month/year):

 /

Policy Term:

 1 year 6 months Other

Current premium:

 $

Current deductible:

 $

Home Information
How long at present address: years months
Number of families dwelling is designed for:
Is business conducted on the premises? Yes No
# of claims in last 3 years:
Distance to a fire hydrant:
Distance to a fire station:

Coverage Information
Value of your personal property:
Value of unit that you are responsible to insure:
(applies to condo only) 
Loss assessment coverage:
(applies to condo only) 
Liability coverage limit:
Deductible:

Additional Comments:
Please give any additional comments about the coverage you desire: