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renters/condo
Schedule Policy Review
Home Quote REQUEST
*This is for informational purposes only. A Crown Island Broker will contact you at the phone number or email address provided. Thank you for the opportunity.
Your first name
Your last name
Email Address
Phone
Street Address
City
State
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
How Did You Hear About Us?
Flyer
Internet
TV
Radio
Other
Square Footage of Property
Current Value $
Year Built (YYYY)
Number of Units
1
2
3
4
Construction Type
Concrete
Log
Masonry
Mason Veneer
Steel
Superior
Other
Roof Type
Composition Shingle
Flat Foam Composite
Flat Membrane
Flat Tar & Gravel
Metal
Tile
Shake
Other
Distance to Nears Fire Station
under 5 miles
5-10 miles
10+ miles
Over 1,000 fee from any fire hydrant?
Yes
No
Fire Extinguisher
Yes
No
Smoke Detector
Yes
No
Dead Bolt Locks
Yes
No
Indoor Sprinkler System
Yes
No
Type of Fire Alarm
Local
Central
Station
None
Type of Burglar Alarm
Local
Central
Station
None
How Much Liability?
$500k
$300k
$100k
How Much Medical Coverage?
$1k
$5k
$10k
$20k
How Much Deductible?
$250
$500
$1,000
$2,500
Have you filed any previous claims?
Yes
No
Do you have a current policy?
Yes
No
If yes, with who?
Additional Comments