Customer Insurance Information Form

Please note that it is important to fill in all the fields before submitting. Thank you.
*Your Last Name :
Middle Name :
*First Name :
*Email address :
*Home Phone #: ()--
Mobile Phone #: ()--
*Current Address:
City :
State :
Zip :
Apt. # :
Description: Motor vehicle Watercraft
Traller Other
Lic. plate #:
V.I.N. or H.I.N. #:
Storage type: Indoor Storage Outdoor Storage

Is there lien or security interest on the personal property? Yes No

Insurance information:
Occupant is self-insured (personally assume risk of loss or damage)
Occupant maintains own insurance policy (Enter Details Below)

Is there a co-owner of stored property ? Yes No

Occupant stores property at their own risk
I understand this self-storage facility and/or its management:
1. Is a self-storage facility renting space and is not a warehouseman or garageman.
2. Is not responsible for loss or damage to stored personal property.
3. Does not provide insurance on my personal property for me; and
4. Requires that I provide my own insurance coverage or be “Self-Insured” (personally assume risk of loss or damage).

Choice of insurance options
My unit/space number:
I, the OCCUPANT of unit/space number have been informed that VINES STORAGE does not provide insurance on my stored personal property. As indicated below, I agree to obtain, and maintain insurance coverage on the personal property stored for actual cash value, or be “Self-Insured” (personally assume risk of loss or damage)

Occupant, please identify your insuranc choice by checking the applicable box below:
Will purchase/obtain from my own insurance provider
Be "Self-Insured" (personally assume risk of loss or damage)
By signing below, I understand and agree to my insurance responsibilities.

*Occupant Signature
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