RENTER’S QUOTE SHEET – Hawaii

Household Information / Name: / Abbey & Hamlet Jones /

Credit:

/ Acceptable
Address: /
2888 NE 12th Ave
/ Email Address: /
City, State, Zip / Ewa Beach, HI 96706 / Date Moved / 8/2004
Home/Work / (808) 677-1212 / Res Type / Single Family Home
Prior Address / 743 Forest Dr., Eagle, ID 83616 /

Referral Source

/ Referral
Miles from Fire Department / 2 / Rsp Fire Dept
County / Ewa Beach
Honolulu County / Distance to Fire Hydrant / 150 feet
Smokers in HH? / No / # Dogs / 1 / Type of Dogs / 1) Collie
Insurance Information /

Policy Number

/ How Long? / Expires /
Premium
Current / None
Previous

Other Allstate Policies:

/

Policy Number

/

Eff. Date

/ Multi-tier Discount ?
New AIC Auto / 322568798977874 / Today / Yes No
Adult Occupants /
Name
/ Relation / Birthdate / Marital Status / Occupation / SSN / Years with Employer
Abbey / Insured / 06/01/1970 / Married / Health Tech / 170-00-0002 / 3
Hamlet / Spouse / 05/03/1968 / Married / Electrician / 000-00-0124 / 2
Kids under 17 / NAME / Relation / Birthdate / Sex
Building Information /

# Family Units in Bldg

/

1

/ / Replacement Cost /

Bedrooms

/ 2 /
Family / Rec Room
/ 0
Unit on floor# / 1 / Kitchen / 1 /

Appliances

/ Yes
Roof Type / Comp. / Living Room / 1 / Window Hangings / Yes
Construction Type /
Frame
/ Dens/Study/Office / 1 / Carpeting / No

Year Built

/ 1989 /

Dining Room

/

0

/
Fire Walls? / N/A
How Many? / N/A /

Dinette / Breakfast

/

Yes

/

# of Rooms

/

5.5

Protective Devices / Dead Bolt Locks-Y
Smoke Detectors-Y
Fire Extinguisher-Y

Personal Property Quality

/ 1. Economy 2. Standard 3. Luxury / Estimated Value:
Coverage & Limit Information /

Standard Coverage/Limits

/
Optional Coverage’s

All Peril Deductible

/

500

/
J – Jewelry
/ 2000

Liability Limit Protection

/ 100,000

Medical Protection Limit

/ 1000 / Scheduled Personal Property / None
Other Coverage’s
/ /

Dwelling Protection

/ N/A
Other Structures / N/A
Personal Property / (Use Estimator)
Personal Property Reimbursement / Yes

Note: This policy will be effective 2 weeks from today.

I:\2_Agency_Staff_Education\ASE_2010\Quia_root_uploads\HI_Abbey_Jones_Renters.doc Revision Date 01/13