Le Claire Insurance

J L Le Claire & Sons Insurance Agency

The Protection and Security you would expect from Family

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Renters Quote

Renters Insurance Quote Request Complete the following information if you would like to obtain a quote. Please understand this is not an application. All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Personal Information *Required
*Last Name
*First Name
*Mailing Address
*City
*State
*Zip Code
Phone Number
Fax Number
Social Security Number
*Birth Date
*Email Address
Property Information
*Property Street Address
*City
*State
*Zip Code
What year was it built?
Total square footage
Number of units
What year was the plumbing updated?
What year was the electrical updated?
What amperage is the service? i.e. 60, 100, 200 amps
What year was the heating updated?
What is the heating source? i.e. gas, electric, etc.
Is there an alarm system?	Yes No
Is there a smoke alarm?	Yes No
Is there a fire extinguisher?	Yes No
Are there deadbolts?	Yes No
*Are there dogs on the property?	Yes No
*If yes, how many and what is the breed of each dog?
*Are there any other pets or animals on the property?	Yes No
*If yes, how many and what is the description of each?
Current Coverage Information
Current Insurance Company
Expiration Date
Current premium
Were there any losses or claims in the last 5 years?	Yes No
If yes, what is the date, amount paid and description of each loss or claim?
Desired Coverage Information
Contents coverage desired (amount)
Policy Deductible
Do you want contents replacement cost coverage?	Yes No
Questions or Comments