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Residence Rented to Others Form
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What is your first name? *
*
What is your first name? *
What is your last name? *
*
What is your last name? *
What is your email address? *
*
What is your email address? *
What is your phone number? *
*
What is your phone number? *
Please enter the address of the location that is being rented.
Please enter the address of the location that is being rented.
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Which best describes the tenant of this property?
Which best describes the tenant of this property?
Family
Friend
What is the length of the rental period?
What is the length of the rental period?
Annual
Short-Term (weekly or monthly rentals for more than 6 months of the year)
Is the location listed on any rental marketplaces? (Select all that apply)
Is the location listed on any rental marketplaces? (Select all that apply)
VRBO
AirBnB
Other
Please list the other marketplace(s) where this location is listed.
Please list the other marketplace(s) where this location is listed.
Please share the listing URL.
Please share the listing URL.
Is the location rented out to corporations or for special events such as weddings or charitable events, etc.?
Is the location rented out to corporations or for special events such as weddings or charitable events, etc.?
Yes
No
Please list the events this location is rented out for.
Please list the events this location is rented out for.
Is there a management company contracted for this rental?
Is there a management company contracted for this rental?
Yes
No
Does the management company have at least $1M in liability coverage?
Does the management company have at least $1M in liability coverage?
Yes
No
Not sure
How is the property maintained?
How is the property maintained?
Caretaker
Property manager
Directly overseen by the member themselves
Does the renter carry their own rental policy for personal property and liability coverage?
Does the renter carry their own rental policy for personal property and liability coverage?
Yes
No
Not sure
Documents and Comments
Please use this field to upload any relevant insurance documents.
Please use this field to upload any relevant insurance documents.
Drop files here or
Select files
Max. file size: 128 MB, Max. files: 10.
Please enter any additional remarks in the space below.
Please enter any additional remarks in the space below.
Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form. Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes. *
*
Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes. *
I agree*
Cecilia Rivera
860-868-7361
http://ericsoninsurance.com/
Cecilia_Rivera@ajg.com
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