Renter's Quote Gallant Risk & Insurance

Renter's Insurance Questionnaire
Full Name*

First NameLast Name
Date of Birth

MonthDayYear
Spouse Name

First NameLast Name
Date of Birth

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number
Please enter a valid phone number.
E-mail
Any other residents? Please list name, DOB and relationship.
Quote Information
Type of Dwelling?

ApartmentTownhouseCondoSingle Family HomeOther
Any Dogs?

NoYes
If yes, what breed(s) and how many?
Daycare business conducted on premises?

NoYes
Are any members of the household self-employed from home?

NoYes
If so, is there any foot traffic?
Please Explain
Any Swimming pools, jacuzzis, hot tubs or spas on the premises

NoYesOther
Protection Details
Fire Extinguishers?

YesNo
Deadbolts?

YesNo
Smoke Alarms?

YesNo
Fire Alarm?

NoCentralDirectLocal
Burglar Alarm?

NoCentralDirectLocal
Coverages
Deductible

$500$1000$1500Other
Liability Coverage Amount

$100,000$200,000$300,000$500,000$1,000,000Other
Medical Payments

$1000$2000$5000Other
Personal Property Coverage Amount (if known)
Loss of Use increase (if known)
Valuable Scheduled Items? Please list with estimated value.
Effective Date of Coverage

MonthDayYear
Will you need a Certificate holder listed? (Landlord or property manager)
Current Declaration Page or other documents

Cancelof
Comments
Should be Empty: