Trahin Miller Insurance Services

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RENTERS INSURANCE QUOTE REQUEST
Personal Information
What is your name?
Last
First
Middle
What is your mailing address?
Street
City
State
Zip
What is your telephone number?
Home
Work
What is the best time to call?
Best Call Time
  AM   PM
What is your fax number?
Fax
What is your email address?
Email
What is your date of birth
(for discount purposes)?
Date of Birth
How would you rate your credit?
Credit
Property Information
Do you currently have renter's insurance?
Renters Insurance
Yes No
If "Yes", when does your current policy expire?
Current Policy Expiration
If "Yes", who are you currently insured with?
Current Policy Carrier
What is your Monthly Rent?
Monthly Rent
What is the square footage of the interior of the rental structure?
Interior Square Footage
What is the approximate year the structure was built?
Approximate Year Built
Amount of Coverage Desired ?
Desired Coverage
Is your home located within 1,000 feet of a fire hydrant?
Fire Hydrant
Yes No
Is your home located within 5 miles of a fire station?
Fire Station
Yes No
Is your home susceptible to flooding or high water?
Flooding
Yes No
Is your home built on a hillside?
Hillside
Yes No
Is your area prone to landslides and/or sinkholes?
Sink Holes
Yes No
Is your home located within a brush hazard area?
Brush
Yes No
Do you have a dog?
Dog
Yes No
Are there any firearms in your home?
Firearms
Yes No
Is there a central alarm system?
Central Alarm
Yes No
Have you experienced any losses or filed any claims within the last 5 years?
Losses in last 5 years
Yes No
How many stories?
Stories
How many rooms?
Rooms
Who lives in the residence?
Residence
Number of occupants in the residence?
Residence Living Number
What part of the year is the house lived in?
Occupancy Time
Do you have a basement?
Basement
Do you have a garage?
Garage
How many bathrooms?
Bathrooms
How many bedrooms?
Bedrooms
How many fireplaces?
Fireplaces
Type of Exterior Walls?
Exterior Walls
Type of roof?
Roof
Age of roof?
Roof Age
Type of Foundation?
Foundation
Questions or Comments

If you have more than 1 residence, please fill out another form

Please Note: Insurance coverage cannot be bound without a written binder from our office.

Please Also Note: Many insurance carriers use information gathered from you and outside sources about your claim, credit history and home. This information allows insurance companies to determine accurately the proper price to charge. You are entitled to a free copy of the reports by contacting the appropriate consumer reporting agency within the next 60 days.

By filling out this form, you agree to the above terms.

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