Disclaimer Notice – The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Further information may be required in order for a complete quote to be provided. This quote request contains some information about coverage offered but it does not list all of the conditions and exclusions that apply to the described coverage. The actual wording of the policy governs all situations.
BY SUBMITTING THIS FORM, I HAVE REVIEWED THE INFORMATION LISTED ON THIS QUESTIONNAIRE AND VERIFY THAT IT IS ACCURATE AS OF THIS DATE. I UNDERSTAND THAT IF ANY OF MY EXPOSURES OR ANY OF MY COVERAGE PREFERENCES CHANGE, IT IS MY RESPONSIBILITY TO NOTIFY RSS AGENCY, INC.