Renters Quote  (Any information is kept confidential and is only for underwriting purposes. This information will only used by Florida Direct Insurance Agency, Inc .or its' subsidiaries only)

 Primary Name          Email  Date of Birth   Social Security # Occupation

Secondary Name (if  applicable)  Email  Date of Birth   Social Security # Occupation

                         Home Phone #        -        -                  Work Phone #         -  -              Cell #   -        -         

Physical Address    City        County  State AL AK AR AZ CA CO CT DE FL GA HI IO ID IN IL KA KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OR OK PA RI SC SD TN TX UT VA VT WA WI WV WY  Zip 

Mailing Address     City            State AL AK AR AZ CA CO CT DE FL GA HI IO ID IN IL KA KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OR OK PA RI SC SD TN TX UT VA VT WA WI WV WY      Zip        

                                            Best Time to Call 8:00am - 9:00am 9:00am - 11:00am 11:00am - 1:00pm 1:00pm - 3:00pm 3:00pm - 5:00pm 5:00pm - 8:00pm                  Best Place to Call  Home Work Cell

Effective Date of Coverage Needed                Prior Insurance Carrier                                Prior Policy #

Date of Expiration of Prior Coverage                    Years With Prior Carrier 0 1 2 3 4 5 or more                         Have You Ever Declared Bankruptcy   Yes   No              

Do You Have Good Credit  Yes    No                      Have you had any homeowner or property related claims in the past five years?   Yes    No

If you have had any losses:

Date     Details of Loss (Be brief)       Amount of Claim

Date     Details of Loss (Be brief)       Amount of Claim

Date     Details of Loss (Be brief)       Amount of Claim

Date     Details of Loss (Be brief)       Amount of Claim

Date     Details of Loss (Be brief)       Amount of Claim

Year Built                  Value of Contents          

Deductible Requested for All other Perils $500 $1000 $2500 $5000 $10000                   

Windstorm Deductible 2% 3% 5% 10%  

Is the Home in a Flood Zone Yes No            

Distance to Fire Hydrant None Other 10 Ft - 100 Ft 100 Ft - 250 Ft 250 Ft - 500 Ft 500 Ft - 1000 Ft 1000 Ft - 2500 Ft 2500 Ft or Greater       

Type of Construction Frame Concrete Block Solid Concrete Concrete/Styrofoam Wood Other   

Square Feet of Home under Roof  

Number of Bathrooms 1 1 1/2 2 2 1/2 3 3 1/2 4 4 1/2 5 5 1/2 6 6 1/2 7 or more            

Number of Fireplaces 0 1 2 3 or more   

Is the Home on piers, stilts, pilings, or other similar structures No Yes  

How many months of the year is the home occupied 0 months 7 months or more 7 months or less 12 months  

Fire Protection None Smoke Detectors Local Fire Alarm Monitored Fire Alarm Sprinklers Local Alarm w/Sprinklers Monitored Alarm w/Sprinklers         Burglar Alarm None Local Alarm Monitored Alarm  

Storm Shutters No Yes - Corragated Panels Yes - Type A Shutters Yes - Type B Shutters Yes - Shutters (Not Rated)  

Screen Porch Yes No       

Swimming Pool No Yes              Is Swimming Pool Fenced or Caged None Caged Fenced        

Is your home located on Open Water, Bay, Gulf, or Ocean Yes No  

Is your Home in a Sub Division Yes No               Is there a Guarded Gate Yes No  

Do you own a Dog Yes No

Additional Information :