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Allied Insurance Brokers Rental Application

By answering the following questions, we can tell you if you qualify for the Hometown Rental Advantage program and provide an estimate on your premium.
Note: Use TAB to skip to the next field.

Business Name:
Contact Name:		Title:
Address:
City:		State:	Zip:
Types of Equipment Rented:
When does your insurance renew?
General Liability:	Property:	Business Auto:	Workers' Comp:
Total revenue for one year:	% of Rental revenue:	% of Sales revenue:	% of Repair revenue:
Total value of equipment:	Do you rent trailers?	Number of homemade?	Do you have kids' rides?
Self storage?	Value of buildings:
Please check the programs you CURRENTLY have in place: Tagging systems Use of short detectors Hold Harmless wording in rental contract
Are you unsatisfied with your current insurance provider?