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First Last Name
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Birth Date
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Second Adult Occupant Name
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Birth Date
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Marital Status
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Address to be Insured
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Apartment # or Unit #
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City
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GEORGIA
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ZIP
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County
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Prior Address
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Prior City and Zip
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Phone Number
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E-Mail Address
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Fire Sprinkler system in unit?
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Yes
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No
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Dead Bolt Lock
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Yes
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No
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Smoke Detector
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Yes
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No
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Fire Extinguisher
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Yes
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No
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Monitored Security System
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Yes
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No
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Gated Community
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Yes
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No
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Community 24 hour Security
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Yes
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No
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Are you currently insured with “Renters”. “Condo” or “home” insurance? (less than 30 day lapse)
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Any Claims in the last 3 years?
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Property Coverage Limit
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Liability Protection Level
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Medical Coverage Level
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Complex Name or Name of Property Management Co.
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Leasing Agent Name
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Phone Number
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Comments
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As part of the application process, we may collect personal information from persons other than you or other individuals proposed for coverage, including credit reports and loss information reports. This information, as well as other personal or privileged information subsequently collected by us, may in certain circumstances be disclosed to third parties without your authorization. You have a right of access and correction with respect to all personal information we collect. If you would like more detailed information in writing about our information collection practices, please let us know.
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NOTE: In regard to the statement above, we are required to post this as a process of obtaining Loss Information History and final quoting criteria. Submitting this form approves the collection of data. We have not asked for and do not require a social security number in this process
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