Tenant Questionnaire CompanyThis field is for validation purposes and should be left unchanged.Name(Required) First Last Date of BirthPhone Number Email Address or Other ContactName (Spouse)Date of Birth (Spouse)Property InformationExterior constructionNumber of units in your buildingAlarm/Home Security or Sprinkler SystemCurrent Insurance InformationCurrent Coverages (Include company, effective date, coverages, deductible & endorsements)Are you comfortable with these coverages or are you interested in comparing any other optionsDeductible options you would considerCoverage NeededValue to REPLACE all of your contents with NEW onesItems you are specifically concerned about replacing (ie Jewelry, Guns, antiques, artwork, etc. List type & Value)Are you concerned about sewer or drain backup damaging your items Yes No Additional InformationNumber of consecutive years you've carried a homeowner-type policy?Have you had a property or liability claim in the last 5 years? (If yes, please list when and what)Smoker/Non-Smoker (All residents)Bankruptcy in the last 5 years? (If yes, when?)Is there a swimming pool, hot tub, bike/skate ramp or trampoline on your property? (If yes, what?)Do you have any pets? (If yes, what breed?)Business conducted on premises? (If yes, what?)Additional InsuredDo you have any toys? (ie boat, motorcycle, atv, snowmobile, golf cart, RV, etc)If you have a copy of your current "Declaration Page", please forward that to us as proof of prior coverage and to use for comparison purposes. Submission of information for a quote in no way binds coverage. Personal information will be used solely for underwriting purposes. Submission of information gives the Gary J Bach Agency permission to run all reports necessary to quote accurate insurance premiums.
