Please complete this form in order to get your apartment/renters insurance quote.

PERSONAL INFORMATION

Your Full Name:

Street Address:

Apartment:

City:

State:

Zip:

Your e-mail:

Phone Number:

Best Time To Call:


APARTMENT INFORMATION

Smoke Detectors:

Construction of Building:

Burglar Alarm:

Number of units in your building:

COVERAGE CHOICES

Are you insuring only your own personal property?

 Yes No

If not, provide name of other person to be insured:

Personal Property Limit:

Personal Liability Limit:

ABOUT YOU

Have you owned a renters policy before?

 Yes No
Any claims in last 3 years? if so, please explain:

Do you own an automobile?

 Yes No

If so, is it registered and insured in MA?

 Yes No

Do you own any pets?

 Yes No
If so, please describe:

Do you conduct business from your apartment?

 Yes No
If so, please explain:

Your occupation:

Would you like specific insurance for personal computers, jewelry, cameras, fine arts?

 Yes No
If so, please explain:

 

Please select one of the following plans:

 Actual Cash Value

Replacement Cost

 

 



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Home of.. Vellucci Insurance Agency
657 Cambridge St. - Cambridge MA 02140
Tel: 617-492-4150 - Fax: 617-492-0139