Insurance Score / Claim History Disclosure

In connection with this application for insurance, we may review your credit report or obtain or use a credit-based insurance score based on the information contained in that credit report. We may use a third party in connection with the development of your insurance score. In connection with this application for insurance, we may review your claims history or loss experience and may report future claims made by you to a claims history provider.

Applicant agrees to these terms. *    

Rental Home Quote Request

Once you complete and submit this form, an agent will contact you within two business
days to provide your quote. For an immediate quote, call 1-866-884-6167 Mon - Fri 8 - 8 ET.

This form allows you to provide information for one rental property. If you have two
or more, we can insure them – just call us!

All fields marked with an asterisk are required. For some of the coverage-specific questions
below, you may find it useful to have your current policy or declarations page handy.

First Name: *    
Last Name: *    
Date of Birth (mm/dd/yyyy): *    
Address: *    
City: *    
State/Province: *    
Zip Code: *    
We apologize that coverage is not available in Florida and New York.

How did you hear about us? *    

Home Information

Please provide the full address of your rental home. *    
Current Value of Home: *    
Year home was built: *    
Approximately how far away (in feet) is the nearest
fire hydrant?    
Is the home currently insured? *    
If yes, who is your current insurance company?    
Is the home a manufactured/mobile home?    
Yes       No      
Is your home inside or outside city limits? *    
Inside       Outside      
How many stories does the home have? *    
What is the home primarily made of? *    
How many homes do you own in total? *    
How many families does the home accommodate? *    
One       Two       Three or more      
Select your desired amount of liability coverage.
The numbers represent the amount of coverage on
the policy per person/per accident/per occurrence.    
Have you had any non-weather related claims on this
home in the past three years? *    
Yes       No      
If yes, please provide the date(s) and some details
about the non-weather related claim(s) here:    

Please provide the following information so we can contact you with your quote.
We respect your privacy and will never sell or rent your contact information to third parties.

How would you prefer that we contact you? *    
Daytime Phone       Alternate Phone       E-mail      
Daytime Phone Number:    
Alternate Phone Number:    
Best Time to Contact    
American Modern may periodically email you news and information
related to specialty insurance products.

If you prefer not to receive these communications, please opt-out here.

Opt-In       Opt-Out      

� 2015, American Modern Insurance Group, Inc., 7000 Midland Blvd., Cincinnati, OH 45102-2607, USA. All rights reserved.

Privacy Policy   |  Contact