Tenant Quote Request - UIS Georgia

Customer Name

Address

Date of Birth

Social Security Number

City

State

Zip

County

Contact Phone Number

Best Time to Call

Email

HOME DETAILS

I want to Insure

Other Insure

Value of Personal Property: $

Liability
100K 300K 500K

Deductible
250 500 1000

Medical Payments
1K 2K 5K

Year Built

Square Feet

Claims in Last 5 Years (include date, loss details, and location)

Style of Home

Type of Siding

Number of Families (Living Units)

Number of Baths (Full)

Number of Baths (Half)

Age of Roof

Enter Year/s (Count)

Enter Month/s (Count)

Age of Electrical

Enter Year/s (Count)

Enter Month/s (Count)

Age of Plumbing

Enter Year/s (Count)

Enter Month/s (Count)

Age of Heating

Enter Year/s (Count)

Enter Month/s (Count)

Feet to Fire Hydrant(ft.)

Miles to Fire Department

Is the Dwelling Located inside City Limits?
Yes No

Does Anyone in the Household Smoke?
Yes No

Do you have Dead Bolts
Yes No

Do you have Fire Extinguisher
Yes No

Do you have Fire Alarm?
Yes No

Do you have Smoke Detectors?
Yes No

Do you have Local Burglar Alarm?
Yes No

Do you have Central Burglar Alarm?
Yes No

Do you have Sprinklers?
Yes No

Property Schedule (list items and value)

Are there any Animals on the Premises?
Yes No

Specify Animal Type and Breed

Do you want to Upload any Document or File?

(".txt", ".doc", ".docx", ".xls", ".xlsx", ".csv", ".pdf" files only)