Name  
  Address  
  Occupation:  
  Policy Period:  
  E-mail:  
  Fax:  
  Home Telephone:  
  Celular Telephone:  
  Business Telephone:  
       
 

Coverages

  
  Primary Residence  
  Physical Address:  
  Type Construction:  
  Levels:  
  Number of Families:  
  Structure Value :  
  Contents Value :  
  Monitored Access Control:  
  Type Access Control:
 Security Guard
Electric /Security Gate
Security Patrol Service		  
     
  Automobile  
 

Description of automobiles:

  
 
Auto 1
Auto 2
Auto 3
Auto 4
Year
Make & Model
Vehicle ID Number
New Cost
Current Cost
Owner's Name (As it appears in license)
Registry No.
License Plate No.
Drop label Exp. Date
Vehicle Type
 
  Type Alarm:  
     
 

Driver Information:

  
 
Name
Age
License Number
Use
Marital Status
 
 

 
       
  Bodily Injury ? Limit :  
  Property Damage ? Limit :  
  Other than Collision Damage :  
   

Deductibles:

    
    Auto 1  
  Auto 2  
  Auto 3  
  Auto 4  
       
     
 

Excess Personal Liability (Umbrella)

 
       
  Limit:  
       
  Jewelry:  
       
  Works of Art:  
       
  Golf Equipment:  
       
  Cameras:

 
       
  Musical Instruments:

 
       
  Contents Replacement Cost :  
       
 

Other Coverages

  
     
 

Other Coverages:
Please submit details of the risk you want to cover and we will revert with the availability and a cost estimate.

  
  Details:  

 

Real Legacy Assurance Company, Inc.

P.O.Box 71467
San Juan, P.R.
00936-8567

Metro Office Park
Calle 1 Lote 4
Guaynabo, P.R. 00968

Subsidiary of

2006 ® Real Legacy Assurance. All rights reserved.