Application for AARP quote

This application is for properties located in Puerto Rico
only. Click here to open the Homeowner and Dwelling application for
properties located in the U.S. Virgin Islands.

(Versión Español)

Name

AARP Member ID

Address

Occupation:

Policy Period:

E-mail:

Fax:

Home Telephone:

Celular Telephone:

Business Telephone:

Coverages

Primary Residence

Physical Address:

Type Construction:

Select... Concrete concrete, wood roof mixed all wood frame other (specify in following box)

Levels:

Select... 1 Level 2 Levels 3 Levels 4 Levels

Number of Families:

Select... 1 Family 2 Families 3 Families 4 Families 5 Families

Structure Value :

Contents Value :

Monitored Access Control:

Select... YES NO

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	Private Leased	Private Leased	Private Leased	Private Leased

Type Alarm:

Driver Information:

Name	Age	License Number	Use	Marital Status
			Select... Job Leisure Business	Select... Married Single
			Select... Job Leisure Business	Select... Married Single
			Select... Job Leisure Business	Select... Married Single
			Select... Job Leisure Business	Select... Married Single

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 :

Select... YES NO

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.