Landlord & Renters Insurance Quote — Lieck Insurance Agency

1Applicant Information

First Name*

Last Name*

Date of Birth*

Driver's License #*

License State*

Phone*

Email*

Preferred Contact*

Marital Status*

Street Address*

City*

State*

ZIP Code*

Co-Applicant's Information(if applicable)

First Name

Last Name

Date of Birth

Driver's License #

License State

Phone

Email

2Rental Property / Properties

Property 1

Property Address*

City*

State*

ZIP*

Year Built*

Sq Footage*

Year Roof Was Replaced

Monthly Rent

Est. Replacement Value

# of Stories

Construction

Roof Type

Property Type

# of Units

Property currently occupied/rented?

Pool or trampoline on property?

3Coverage Needs

Loss of rental income coverage?

Flood coverage?

Umbrella coverage?

Liability coverage desired?

4Current Insurance

Currently insured?

Please upload your current declarations (dec) page or any additional documents in Section 6 — this helps us find you the most accurate quote.

5Claims History & Tenant Policies

Any claims in the last 5 years?

Do you allow pets?

Do you conduct background checks on tenants?

6Additional Information & Consent

Anything else we should know?

Upload Documents (Optional)

Upload your current declaration page, policy documents, or any other relevant files. You can also take a photo directly from your phone.

Accepted: Images (JPG, PNG), PDF, Word docs. On mobile you can take a photo directly.

I certify that the information provided is accurate and complete to the best of my knowledge.

I agree to be contacted by Lieck Insurance Agency regarding this quote.