VACANT BUILDING/BUILDING UNDER RENOVATIONS …...ACV of Existing Structure $ ACV of Amount of...
Transcript of VACANT BUILDING/BUILDING UNDER RENOVATIONS …...ACV of Existing Structure $ ACV of Amount of...
VACANT BUILDING/BUILDING UNDER RENOVATIONS APPLICATION
Requested policy term: 3mo___ 6mo___ 12mo___ Requested Effective Date: ___/___/___ Prior Exp. Date:___/___/___
Applicant Signature (Required to Bind): ________________________________________________ Date: _____________
Prior Carrier: ___________________________ Has coverage been declined/cancelled/non‐renewed? YES NO
Applicant/Co‐Applicant Information Applicant: __________________________________ Telephone Number: ( ) ______ ‐ _______
Mailing Address: _____________________________________________________________________________________________________
Occupation: __________________________________ Employer Name: __________________________________ Years w/ Employer: ______
Rating/Underwriting Information Location Address: ____________________________________________________________________
How long has applicant owned building? _________ If purchased w/in past year, indicate purchase price $_____________________________
Prior use of building when occupied: ____________________________ Intended Disposition: _______________________________________
Please confirm weekly checks are made to the premises? YES NO By whom? ______________________________________________
Protection Class: ____ Distance to; Hydrant: ________ Fire Dept: _______ Lot Size (acres): _____Year Built: ______ Sq Footage: __________
NUM OF AMPS (ELEC SYST)
CIRCUIT BREAKERS FUSES KNOB & TUBE OR ALUMINUM WIRING
YES NO YES NO YES NO
Is electricity maintained year round? YES NO When were wiring, heating, plumbing & roofing last fully updated? Wiring: _______ Heating: _______Plumbing: _______Roofing: _______
Please confirm whether all pipes are drained and water is shut off during winter months. YES NO
If NO, what is the primary source of heat? ___________________ Is fuel setup for automatic delivery? YES NO
Property Coverage Desired Coverage Limit
ACV of Existing Structure $
ACV of Amount of Renovations To Be Conducted $
Personal Property $
Premises Liability (please select)
Medical Payments (please select)
Check ALL boxes below that DEFINE the work being done: (If additional space is needed, attach separate sheet.) Replacing Bathroom Fixtures Replacing Roof Replacing Windows Siding or Painting Exterior Replacing Kitchen Cabinets Replacing Floors Replacing Exterior Doors Gutting the Premises Replacing Plumbing/Heating/Electrical Painting Other (Specify):
Will ANYONE other than the applicant be conducting renovations? YES NO (All subcontractors must have a CGL policy in force.)
LOSS HISTORY (Last 3 years):
Year Payout Amount Description – Damages Repaired?
MORTGAGEE CLAUSE: ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________
Retail Agent Information
Agency: _________________________________________________ Mailing Address: __________________________________________Phone: ( ) _______ ‐ _________ Fax: ( ) _______ ‐ _________ Contact E‐mail: ___________________________________________