South Bay Renters—Country Brook Application, Proof of Insurance is sent by email.


—Please read everything.
—Fill out this form completely
—Submit this online application
—Submit online payment
—Thank you

Resident New Resident
Start coverage date

First & Last Name/Renter 1
Phone 1
Date of Birth 1
Social Security Number 1
Email 1

First & Last Name/Renter 2
Phone 2
Date of Birth 2
Social Security Number 2
Email 2
Do all household members qualify for Non-Smoker rates? Yes No

Address Apt

Policy Coverage with $1000 deductible—
Contents replacement, Annual Premium 108.11 — onetime fee $12,

Total Due Today $120.11
Personal Property
Lose of Use
Personal Liability
Medical Payments $1,000

Visa MasterCard Number Exp. zip CVV #
Name on Credit Card

Special Comments
Terms & Conditions

The full insurance policy is my contract for insurance, not this online form. I understand that the full insurance policy will be mailed to me within 20 days.

I understand that coverage begins upon receipt of payment and confirmation of the requested effective date.

I understand there may be a cancellation fee if I cancel the policy mid-term.

I understand that the rates quoted are based on residence in the chosen apartment community, and that quoted rates assume a claim-free history, non-smoker discount, and are subject to change.

I understand that my eligibility for this Renters Insurance Program is based on residing in this approved apartment community, and I agree to notify within 10 days of any change of address.

Acceptance & Notice

Any person who, with intent to defraud or clearly knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

I understand that the owner of this Farmers Insurance approved apartment community may receive a copy or be notified of any notice of cancellation or nonrenewal of my policy.

My eligibility for the Farmers Insurance program is based on residing in this qualified apartment community, and I agree to promptly notify the program administrator, Mark Cassin, if I change my residence.

The policy is my contract for insurance, not this Election Form. Farmers Insurance will send my policy within 15 days.

My coverage begins upon receipt and confirmation of the Requested Effective Date by Farmers Insurance.

By clicking "Submit" I agree to the Terms, Conditions, Acceptance & Notice listed above.

South Bay Renters Insurance Program underwritten by Farmers Insurance Group of Companies
California Department of Insurance - License # 0F26894. Copyright © 2008