Form to Claim Renters Insurance

							                         AMERICAN BANKERS INSURANCE COMPANY OF FLORIDA
                                        11222 Quail Roost Drive, Miami FL 33157 - 6596 (305) 253-2244




              REQUEST TO INC REASE COMPREHENSIVE PERSONAL LIABILITY COVERAGE FOR
                                      RENTERS INSURANCE

        Please provide the following information. Sign this form and return it to the address indicated below.

                                                               INSURED

NAME                                                                 POLICY NUMBER                       HOME TELEPHONE NUMBER




ADDRESS                                                                                                  WORK TELEPHONE NUMBER




                                        LIMIT OF COVERAGE REQUESTED
                                    Comprehe nsive Personal Liability: $100,000

1. Any business conducted on the insured premises?                                             Yes ____            No____
   If so, describe: _____________________________________________________________________
2. Have you reported any personal liability claims in the past 3 years?                        Yes ____             No____
   Date of Loss: ______________________ Date of Loss: _______________________
   Date of Loss: _______________________ Type of Loss: _______________________
   Amount Paid: _______________________ Amount Paid: _______________________
3. Do you own any pets or animals?                                                             Yes ____             No____
   How many?________________________________________________________________________
   Describe animals (if dogs, list breed): ___________________________________________________

                  The following dog breeds are unacceptable:
                           Pit bull, German Shepard, “Husky Type”, Malamute, Doberman Pinscher, Chow, Great Dane,
                           St. Bernard, Akita, and any “mixed breed” that includes the aforementioned breeds.

  Have any of your animals caused bodily harm or injury in the past?                                    Yes ____ No ____
  Have any of the animals been trained to attack or guard premises?                                     Yes ___ _ No ____
  Are the animals restrained when outside the home?                                                     Yes ____ No ____


Submission of this request does not guarantee coverage. Request must be reviewed and accepted before coverage will be bound. If your
request is not accepted, your personal liability coverage will be reduced to $50,000 and any applicable premium will be refunded.
Coverage will be effective the date of acceptance by American Bankers Insurance Company of Florida and its authorized
representatives.

I hereby request that my Comprehensive Personal Liability coverage be increased to $100,000. I understand that this change will
increase my premium. I certify that the answers to the above questions are true and correct.


                                                                                                                     /      /
AGENT                                               INSURED SIGN ATURE
                                                                                                          DATE




Fraud Notice - Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance or statement of claim containing any materially false information or
conceals, for the purpose of misleading, informat ion concerning any fact material thereto, commits a
fraudulent insurance act, which is a crime, and may subject such person to criminal and substantial civil
penalties.
(See reverse side for additional Fraud Notices)
M3656-0199
                                       FRAUD NOTICES


FLORIDA:      Any person who knowingly and with intent to injure, def raud, or deceive
              any insurer files a statement or claim or an application containing any
              false, incomplete, or misleading information is guilty of a felony of the
              third degree.

NEW JERSEY:   Any person who includes any false or misleading information on an
              application for an insurance policy is subject to criminal and civil penalties.

VIRGINIA:     It is a crime to know ingly provide false, incomplete or misleading information
              to an insurance company of the purpose of defrauding the company.
              Penalties include imprisonment, fines and denial of insurance benefits.