Insurance Score / Claim History Disclosure
In connection with this application for insurance, we may review your credit report or obtain or use a credit-based insurance score based on the information contained in that credit report. We may use a third party in connection with the development of your insurance score. In connection with this application for insurance, we may review your claims history or loss experience and may report future claims made by you to a claims history provider. 
 
 
 
Applicant agrees to these terms.*
 
 
 
 
 
 
 
Vacant Home Quote Form
 
 
 
 
When you fill out and submit this form, one of our agents will take your information and provide you a quote within two business days. If you would like an immediate quote, call 1-866-884-6167 Mon - Fri 8 a.m. - 8 p.m ET.

This form allows you to provide information for one boat. If you have two or more boats, we can insure them – just call us!

All fields marked with an asterisk are required. You may find it useful to have your current policyor declarations page handy.
  
 
 
 
First Name*
 
 
 
 
Last Name*
 
 
 
 
Email*
 
 
 
 
If you do not have an email address, please give us a call at 866-880-8651. 
 
 
 
Date of Birth (mm/dd/yyyy):*
 
 
 
 
Address*
 
 
 
 
City*
 
 
 
 
State*
 
 
 
 
Zip Code:*
 
 
 
 
We apologize that coverage is not available in Florida and New York.
 
 
 
How did you hear about us?*
 
 
 
 
If Agent, who is the agent?
 
 
 
 
 
 
 
Home Information
 
 
 
 
 
Is the home located at a different location than the mailing address you provided above?
 
Yes
No
 
 
 
If you answered Yes, it is important that you provide the Address, City, State and Zip:
 
 
 
 
How long do you want your policy to be in effect? Note that your policy will automatically renew for as long as you need coverage.
 
 
 
 
How long has the home been vacant?*
 
 
 
 
Tell us why the home is currently vacant.*
 
 
 
 
Is the home currently insured?*
 
 
 
 
If yes, who is your current insurance company?
 
 
 
 
Current Value of Home:*
 
 
 
 
Year home was built:*
 
 
 
 
Is your home inside or outside city limits?
 
Inside
Outside
 
 
 
Is the home a manufactured/mobile home?*
 
Yes
No
 
 
 
Approximately how far away (in feet) is the nearest fire hydrant? *
 
 
 
 
How many families does the home accommodate?*
 
 
 
 
How many stories does the home have?*
 
 
 
 
Have you had any non-weather related claims on this home in the past three years? *
 
Yes
No
 
 
 
What is the home primarily made of?*
 
 
 
 
How much personal property coverage do you need? *
 
 
 
 
How much personal liability coverage do you need?*
 
 
 
 
 
 
 
 
 
 
Please provide the following information so we can contact you with your quote.
We respect your privacy and will never sell or rent your contact information to third parties.
 
 
 
 
 
 
How would you prefer that we contact you?*
 
 
 
 
Daytime Phone Number
 
 
 
 
Alternate Phone Number
 
 
 
 
 
 
 
Best Time to Contact
 
 
 
 
 
 
 
American Modern may periodically email you news and information related to specialty insurance products.
 
 
 
If you prefer not to receive these communications, please opt-out here.
 
Opt-In
Opt-Out