Tenant Questionnaire

Name

Name (Spouse)

Date of Birth

Date of Birth (Spouse)

Phone Number

Email Address or other contact

Property Info:

Exterior construction

# of units in your building

Alarm/Home Security or Sprinkler System

Current Insurance Info:

Current coverages
(Include company, due date, coverages, deductible & endorsements.)

Are you comfortable with these coverages or are you interested in comparing any other options

Deductible options you would consider

Coverage Needed:

Value to REPLACE all of your contents with NEW ones

Items 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
YesNo

Additional Info:

# 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 Insured

Do 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.