Tenants

Tenants Online Quote - HO-4

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Agent Information

Agency Name

-OR-

Agent Lookup Code

Agent Names

Agent Name (first and last)

Phone:

Fax:

Agent Email:

Agency's Mailing Address

Agency City

Agency State

Agency Zip

Insured Information

Insured Name:

Insured Email:

Insured Phone Number:

Date of Birth:

Occupation:

Employer:

Is there an additional resident or spouse?

Dwelling Address:

Dwelling City

Dwelling State

Dwelling Zip

Is the Mailing Address the same as the Dwelling Address?

Mailing Address

Mailing City

Mailing State

Location Zip

Effective Date

Proposed Effective Date:

Dwelling

Year Built:

Dwelling Area (sq. footage):

Number of Stories:

Protection Class:

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?

Is the applicant a student?

Insurance History

Has there been any Prior Insurance on this Account?

* Please provide an explanation in the Additional Comments section at the bottom of the page

Loss History

Any Open Claims?

Number of Losses in the Last Five Years:

#

Date (MM)

Date (YYYY)

Loss Type

Details

Paid Out($)

1

2

3

4

5

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.

Coverages

Replacement Cost Personal Property

Commission

What commission would you like for this account?

Additional Comments

Any Additional Comments

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If you are seeing this message then you do not meet these requirements.

For higher limits or coverage options not listed, please contact our Personal Lines Department, Ext 600.

Any questions or problems with the form? Please contact our Personal Lines Department

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

Tenants Online Quote - HO-4

Agent Information

Insured Information

Effective Date

Dwelling

Applicant

Insurance History

* Please provide an explanation in the Additional Comments section at the bottom of the page

Loss History

#

Date (MM)

Date (YYYY)

Loss Type

Details

Paid Out($)

1

2

3

4

5

Coverages

$20,000 minimum value is included with the policy. Increase value if more coverage is required.

Limit of Liability: $100,000 Included

Coverage D defaults to 10% of the Value of Contents.

Coverages

Commission

Additional Comments

Submission Failure