NCRentersInsurance.com: North Carolina Rental Insurance

Renter's Insurance Application

User Information

Coverage Information

General Information

Applicant Information

Previous Address(If less than 3years)	:
Years at previous address	:
Location of Property if Diff From Above	:
Applicants Occupation	:
Applicants Employer Name	:
Applicants Employer Address	:
Year in Current Occ	:
Years W/Curr EMPL	:
Years W/Prior EMPL	:
Marital Status	:
Date of Birth	:

User Information

Coverage Information

General Information

Coverages/Limit Of Liability

Rating/UnderWriting

Frame	:
Masonary	:
Masonary Veener	:
Fire Res	:
MFG Home	:
Vinyl siding	:
Aluminium Siding	:
Year Built	:
Sq Ft	:
# Rooms	:
# Apts	:
Market Value($)	:
Replacement Cost($)	:
Structure Type	:
Usage Type	:
# Families	:
# HouseHolders	:
Purchase Date/Price	:
# Fire DIVS	:
# Units in Fire DIVS	:
Fire/EC Rate	:
Fire District/Code Number	:
Terr Code	:
Prem Group	:
Protect Class	:
Distance To Hydrant(FT)	:
Distance To Fire Station(MI)	:

Protection Device Type

Central	:
Direct	:
Local	:

Heat Type

Primary	:
Secondary	:
House Keeping Condition	:

Renovation Type

Wiring	:
Plumbing	:
Heating	:
Roofing	:
Exterior Paint	:
Date Heating System Last Received	:
Number of Amps(Elec Sys)	:
Circuit Breaker	:
Fuses	:
Knob and Tube Or Aluminium Wiring	:
Plumbing and System Condition	:
Plumbing System Any Known Leaks	:
Foundation	:
Dwelling Location	:
Occupancy	:

Oil Storage Tank Location

Indoors	:
Outdoors	:

Swimming Pool

Swimming Pool	:
If Yes	:
Location	:
Windstorm Loss Mitigation Features	:

Building Code Grade

Inspected	:
Tax Code	:
Rating	:
Occupancy Daily?	:
# Weeks Rented	:
Wind Class	:
Roof Material	:
Condition of Roof	:
Basement(SQ FT)	:
Garage(SQ FT)	:
Breezeway(SQ FT)	:
Rating Credits	:
Sprinkler	:

Fireplaces(Enter Number)

Chimneys	:
Hearths	:
Pre-Fab	:
Wood Stove Insert	:

Prior Coverage

User Information

Coverage Information

General Information

Any Farming Or Other Business Conducted on Premises	:
Any Residence Employees	:
Any Flooding,Brush,Forest Fire Hazard,Landslide,etc?	:
Any Other Residence Owned,Occupied or Rented	:
Any Other Insurance with this Company	:
If Yes,List Policy Numbers	:
Has Insurance been transferred within agency	:
Any Coverage Declined,cancelled or non-renewed during the last 3 years	:
Has Applicant Has a Foreclosure,repossession,bankruptcy,judgement or lien during the past 5years	:
Are there any animals or exotic pets kept on premises?	:
Distance to Tidal Water	:
Is property situated on more than 5 acres	:
Does Applicant Own Recreational vehicles	:
Is Building Retrofitted for EarthQuake?	:
Is there a manager on the premises	:
Is there a security attendant	:
Is the building entrance locked?	:
Any Uncorrected Fire or Building Code Violations	:
Is Building Undergoing Renovation or Reconstruction	:
Is House for Sale	:
Is propert within 30ft of a commercial or non resedential property	:
Is there a trampoline on the premises	:
Was the structure originally built for other than a private residence and then converted	:
Any Lead Paint Hazards?	:
If a fuel Oil tank is on premises,has other insurance been obtained for the tank?	:
If building is under construction,is the applicant the general contractor?	:

Name	:
Address	:
Loan Number	:
Estimated Gross Receipt for proposed policy period	:

Remarks	: