Renter's Insurance Quote Form

First Name *

Last Name *

Phone *

Email *

Date of birth *

Property Address

Address *

State *

City *

Postal code *

Property Info

Does The Property Have

Fire Alarm

Burglar Alarm

Additional Roommates

Any Additional Roommates? *

Roommate #2 Information

Name (Roommate #2)

Phone Number (Roommate #2)

Email (Roommate #2)

Date Of Birth (Roommate #2)

Start Date & Base Coverage Packet

When do you need the policy to start? *

Would you like Good, Better or Best Coverage? *

Additional Coverage Package

Yes

Additional Coverage Package includes the following coverages:

Special Personal Property Coverage
Replacement Cost Contents
Refrigerated Property Coverage-$500
Personal Injury

How Much Coverage Do You Need?

Personal Property Coverage *

Please select the amount that covers ALL personal property of Insured. We recommend $10,000 per insured/person.

Personal Liability Coverage *

Please select the amount of personal liability coverage that is needed.

Medical Payments *

Deductible *

Please select the deductible amount you want.

Loss of Use (Enter Amount)

Optional Coverage. Please enter the amount of loss of use coverage needed.

Loss of Use Coverage

Loss of Use Coverage Declined

Additional Questions

1. Is your entire home or any part of it available for rent, including short-term vacation rental or home sharing/swapping? *

Yes

2. Do you or any household member have any pets or animals that have bitten or injured anyone? *

Yes

3. Do you or any household member own one or more of the following breeds or a mix of one of these breeds of dogs? Akita, Alaskan Malamute, American Bull Terrier, American Staffordshire Terrier, Mastiffs, Chow Chow, Doberman Pinscher, Pit Bull, Presa Canario, Rottweiler, Staffordshire Bull Terrier, Wolf Hybrid. *

Yes

4. Have you lived at another address in the last six months? *

Yes

5. If Yes, what was the address?

Disclosures

To provide you with an accurate quote, we obtains information about you and other household members from consumer reporting agencies. This includes credit-based insurance score, driving and claim histories and other consumer reports. They use this information to underwrite and rate your policy. They may order additional reports to update or renew your insurance. Travelers may use a third party to develop a credit-based insurance score. Not all reports are ordered in all states. Travelers Privacy Policy explains how Travelers discloses and protects information. *

I have read and agree with the above statement.

Consent & Authorization

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. Text HELP to 1-(855) 449-8552 for assistance. You can reply STOP to unsubscribe at any time.

I hereby certify that all information provided in this insurance application form is accurate and complete to the best of my knowledge. I understand that Peak Insurance is not responsible for any errors, omissions, or inaccuracies in the information I have provided. Furthermore, I acknowledge that any discrepancies or mistakes in the information submitted may affect the coverage and benefits provided by Peak Insurance. I agree to review my policy documents upon receipt and notify Peak Insurance immediately of any errors or omission.