Please fill in and submit the information below. I'll take care of the rest.
Items followed by an asterisk (*) are required.
Contact Information
First Name*
Last Name*
Address
Unit #
City
State
Zip Code
Home Phone*
Work Phone
Ext
Email
Your Rental Property Information
Address*
Unit #
City*
State*
Zip*
Number of units in your building*
Number of Stories*
Year Built*
Living Area Square Feet*
Security Options:
Alarm System
Fire Extinguisher
Automatic Fire Sprinklers
Smoke Detectors
Dead Bolt Locks
Questions
Birthdate (xx/xx/xxxx)*
Age*
Smoker*
Yes
No
Desired Personal Property Coverage*
$10,000
$20,000
$30,000
$40,000
$50,000
Other
Desired Comprehensive
Personal Liability*
$100,000
$300,000
$500,000
Desired Deductible Amount
$250
$500
$1000
$2000
To receive a larger discount, would you consider also
insuring your auto(s) with Farmers?
Yes
No
If you have coverage now, who is your insurer?
If you have coverage now, when does it expire?
If you have had any reported claims in the last three
years, please explain:
How should we contact you?
Home Phone
Work Phone
E mail
What time should we contact you?
Do you have any questions or suggestions?
copyright 2003, Carolyn Colteaux Insurance Agency, Scottsdale, Arizona
Privacy Statement
Website Design:
Alico Design, Inc.
