Minnesota Renters Insurance Quotes Gerry Smith Insurance Agency of Burnsville Minnesota Free Online MN Renters Tenants Apartment Personal Property Insurance Rate Quote Inquiry Form

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PERSONAL INFORMATION
First Name	MI
Last Name
Address
City
*State*
Zip Code
Date of Birth	Social Security Number
*Spouse's Date of Birth* (if applicable)	Spouse's Social Security Number

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PROPERTY COVERAGES

Personal Property $         Contents Replacement Cost

Loss of Use

Personal Liability $

Guest Medical $

Additional Coverage 1)          Amount $

Additional Coverage 2)           Amount $

Additional Coverage 3)           Amount $

Deductible $

Current Insurance Company

GENERAL INFORMATION

Year Built               Number of Units in Bldg

Non-Smoker Yes No

Protective Devices 1)

Protective Devices 2)

Claims (Last 3 Years)
Date (mo/yr)               Description

Claim #1



Claim #2



Claim #3

CONTACT INFORMATION

Preferred Method of Contact

E-mail

Phone Number

Fax Number

Postal Mailing Address

Questions or Comments

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PERSONAL INFORMATION

PROPERTY COVERAGES

GENERAL INFORMATION

CONTACT INFORMATION