Tenant Policy Change Request – Rayner Agencies Ltd.

Please fill out the policy change form below. During business hours, you can expect a representative of Rayner Agencies Ltd. to contact you within 30 minutes. Thank you for your patronage!

Personal Information

First Name

Date of Birth

Phone Number

Preferred method of follow-up

Phone

Last Name

Email Address

Mailing Address/Legal Location

Birthdate of Eldest Occupant

Sewer Backup

Yes

Type of property

If apartment style, what floor?

Limit on personal property

Deductible

Prior Insurance History

Prior Insurance Company

Policy Number

Claims in Past 5 Years? If so, please describe.

Consecutive Years Insured

Confirmation

Date

Approval

Consent

By selecting Consent, I agree that that the policy change requested is not bound until confirmed by your broker.

Signature of Insured