Verne Hart Insurance | Home - Renters

Name
Address
City,St,Zip
Home Phone	- Best Time to Call
Work Phone	-
Fax Phone	-
E-Mail
Type of Policy
Current Insurer
Does your policy renew within 12 days? Yes No
Is this quote for a new home purchase? Yes No
Closing	Month Day
RESIDENTIAL DATA
Homeowners	Amount of coverage on dwelling (ie.100,000) $
Renters/Condos	Amount of coverage on personal property (ie. $25,000 - Minimum $10,000) $
ZIPCODE of Property		Deductible Amount
Construction Type		Design Type	# of Stories
Basement		Square Footage
Garage Type
Fire Station
Year Built	Approximate
PLEASE CHECK ALL THAT APPLY

CLAIM/LOSS INFORMATION

Please describe any Claims or Losses you've had in the past 3 years