Landlord Quote

Last Name
First Name
M. I.
Physical Address
City
State
Zip
County
Mailing Address (if different)
City
State
Zip
County
Email
Home Phone
Cell Phone
Work Phone
Building Construction Type		Please Select Frame Stucco Brick/Stone Shingle/Wood Siding Aluminum/Vinyl Siding
Number of Units		Please Select One-Family Two-Family Three-Family Four-Family More
Year Built
Date of last update to Plumbing
Date of last update to Heating
Date of last update to Roof
Date of last update to Wiring
Within 1,000 ft of Fire Hydrant		Please Select Yes No
Distance to Fire Department in Miles
Amount of Insurance for Building
Amount of Insurance for Contents
Building Valuation		Please Select Replacement Cost Actual Cash Value
Liability Amount		Please Select 100,000 300,000 500,000 1M
Med Pay		Please Select 1,000 2,000 4,000 5,000
Deductible		Please Select 250 500 1,000 1,500 2,000
Smoke Detectors?		Please Select Yes No
Carbon Monoxide Detectors?		Please Select Yes No
Alarm?		Please Select Central Station Local Alarm
Sewer and Drain Coverage?		Please Select Yes No
Claims/losses in the last 5 years		Please Select None 1 2 3 4 More
Please provide date, amount and brief description of each incident
Present Insurance Company
Renew Date
Are you being Cancelled?		Please Select Yes No
Add Landlord Umbrella/Landlord Catastrophe Liability coverage?		Please Select 1M 2M 3M 4M 5M Not at the time
Do you have any questions or additional information/comments?

Bradley Agency Disclaimer for On-Line Quote By choosing to use this web site (bradleyagency.com) to request an insurance quote, you agree to the following terms and conditions. The materials and information contained in this web site are provided “as is” and without warranty of any kind, either expressed or implied.  The Bradley Agency assumes no liability whatsoever for damages of any kind incurred as a result of your request for a quote or use of this website. Your request for an insurance quote will not bring into effect any insurance coverage.  Insurance coverage may only be effected when your application for insurance is accepted by the Bradley Agency and approved by the carrier as evidenced by the inception date as indicated on a policy. Your entire quote, including the estimated premium and the prospective terms of coverage are tentative and are subject to change without notice based on any and all underwriting criteria, rating dates, manuals, plans and classifications used by Bradley Agency. In the event that there is a difference in the information, rates, premiums or terms contained in a quote and any insurance policy issued to you by the Bradley Agency, the policy governs.