Application for Tenant Default Insurance
Landlord's Name*
First Name Middle Name Last Name
Landlords Mailing Address*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code Country
Landlord's Telephone Number*
Area Code Phone Number
Rental Unit Address*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Lease Start Date*
Month Day Year
Date
Lease End Date*
Month Day Year
Date
Monthly Rental Amount*
Name of Tenant*
First Name Middle Name Last Name
Tenant Phone Number*
Area Code Phone Number
Tenant Email Address*
example@example.com
Association Membership (if any)*
AAOC AAGLA AACSC SoCalRHA NCRPA
APPLICANT’S ATTESTATION
1. I have conducted a tenant screening and have obtained a tenant screening report from
an independent third party, which contains the following information about the tenant:
a) Credit check or credit report;
b) Prior evictions report;
c) Criminal records search.

2. The third-party screening report confirms that the tenant has a FICO score of at least 590.
3. The third-party screening report confirmed that the tenant received has not had a prior eviction, lease payment default, or criminal conviction within the past 5 years.

4. I have received a signed application to rent from the tenant.

5. I have executed or will execute a written lease agreement with the tenant prior to the tenant move-in date.
6. I will retain copies of the tenant screening report, application to rent, and written lease
agreement, and understand that I must make copies of these available to the insurance company in the event I make a claim under this insurance.
7. I have read and understand the Important Notice in this application for insurance. Signature Required*
Clear
IMPORTANT NOTICE
ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON, FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION, CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, DC, FL, HI, MA, NE, OH, OK, OR, VT, or WA; in LA, ME, TN, and VA, insurance benefits may also be denied).
THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE ENQUIRY HAS BEEN MADE OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT, AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE.
"BY TYPING MY NAME HERE, I DECLARE THAT I AM AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENT THAT A REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO THE QUESTIONS ON THIS APPLICATION. I REPRESENT THAT THE ANSWERS ARE TRUE, CORRECT, AND COMPLETE TO THE BEST OF MY KNOWLEDGE."
Applicants Signature*
Clear
Date*
Month Day Year
Date
Should be Empty:

Application for Tenant Default Insurance