First Name 

Last Name 

Address 

City    

County 

State KY                Zip Code

E-Mail 

Do you currently have renter's insurance?

SELECT ONE YES NO

If Yes, with what company?

What is the expiration date of your current policy?

What is the current insured replacement cost of your personal items? 

What year was your home built? 

Construction Type:  SELECT ONE BRICK FRAME OTHER

If other, please specify 

Which deductible would you like?  SELECT ONE 250 500 1000

Liability Limit:  SELECT ONE $100,000 $300,000 $500,000

Do you have a wood burning stove?  SELECT ONE YES NO

Does your home have any business exposure?  SELECT ONE YES NO

If yes, please describe:

Do you have any pets or exotic animals?  SELECT ONE YES NO

If yes, please describe (type and breed):

Is there a trampoline on your property?  SELECT ONE YES NO

Have you filed for bankruptcy in the past 5 years?  SELECT ONE YES NO

How far is it to the nearest responding fire department?

SELECT ONE O TO 5 Miles 5 TO 7 Miles 7 TO 10 Miles Greater than 010 Miles

What is the name of the responding fire department? 

How far is the closest fire hydrant?  SELECT ONE LESS THAN 1000 FEET GREATER THAN 1000 FEET

Have you had any claims under your current renter's insurance or any other renter's insurance?  SELECT ONE YES NO

If yes, describe below:

How did you hear about us? SELECT ONE SEARCH ENGINE YELLOW PAGES BILLBOARD TELEVISION