Renters Insurance Quote Form Ledbetter Insurance Renters Quote Form We would love to hear from you! Please fill out this form and we will get in touch with you shortly. 1 Personal Information2 Property Information3 Current Coverage Information Insured Last Name:Insured First Name:Insured Middle Name:Property Address Street:City:State:IllinoisIndianaIowaMississippiMissouriOhioWisconsinZip Code:Return Call Phone NumberEmail* Date of Birth (For discount purposes):* Date Format: YYYY slash MM slash DD How would you rate your credit?:ExcellentAbove AverageAveragePoor What is the Dwelling Type?HouseDuplexApartmentNumber of Units in your building:What year was it built?:What is the construction type?:BrickStoneFrameMasonrySuperiorLog CabinFrame-StuccoMasonry VeneerAsbestos ShingleAre there dogs on the property?:YesNoIf yes, how many and what is the breed of each dog?: Current Coverage InformationWhere there any losses or claims in the last 5 years?:YesNoIf yes, what is the date, amount paid and description of each loss or claim?:Desired Coverage InformationHow much contents coverage do you want?:How much Personal Property Coverage do you want?:*($6000 minimum to $150,000 maximum)Premises Liability Coverage amount:*$100,000$300,000$500,000Medical Limit amount:*$1,000$2,000$5,000$10,000How much liability coverage do you want?:$100,000$300,000$500,000Policy Deductible:$500$1000Do you want replacement cost on your contents?YesNoMode of payment:MonthlyQuarterlySemi-AnnualAnnualQuestions or CommentsNOTICE: Some companies use an insurance score. This can often improve your rate. If you would like us to use this underwriting tool please provide us your social security number in the remarks box below. (Rules of the Fair Reporting Credit Act and Federal Consumer Credit Protection Law, will apply)Comments:NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.