Get A Quote

BASIC POLICY HOLDER INFORMATION

THIS IS NOT A POLICY OF INSURANCE. THIS IS AN APPLICATION TO RECEIVE A QUOTE AND PROVIDES NO COVERAGE WHATSOEVER.
To fully understand your needs, a representative will contact you within 1 business day to discuss your application.


* - Required Field

*Policy Holder Name (How is the property titled?)
*Address (EXAMPLE-WHERE POLICY WILL BE MAILED-Cannot be a P.O. Box)
*City
*State
*Zip
Is your mailing address different from above?
Mailing Address
City
State
Zip
*Phone Number
*Email
Cell Phone
Fax Number
Contact

*Are you a licensed insurance agent?
Agent’s Name
Agent’s Phone Number
Agent’s email address
Are you an Investor or Lender?
Years in Business
*How did you hear about us ?
Has Applicant ever filed for bankruptcy ?
Total number of all Investor-owned property
What percent is Residential?
What percent is Commercial?
Are any of these properties mobile homes?
How many properties are mobile homes?
IMPORTANT: This policy provides coverage for Mfg. & Mobile Homes but must be listed as such for coverage to be in place. Be advised, Mfg. & Mobile Home have a higher deductible and rates.
Do any locations have a known pollution exposure?

COVERAGE DESIRED
Effective Date Coverage Desired
Check All Coverage Desired
Investor Owned PropertyPremises Liability for Investor Owned Property

PREMISES LIABILITY REFUSAL AFFIRMATION
By checking the below checkbox, I affirm that I understand that premises liability has been offered to me and I have elected NOT to have this coverage.
I affirm

STANDARD DEDUCTIBLES: RESIDENTIAL $2,500 COMMERCIAL $5,000
Would you like a different deductible?
Please specify the amount

Will you hold the loan on any Investor Property you sell?
Is Forced Place Coverage desired?
Are any properties rented?
Are you interested in Loss of Rents coverage?
Please select preferred billing cycle
Invoice billing is emailed. Would you prefer an alternate method?

Billing Information
*Billing Contact email address
Billing Contact Name
Billing Address
Billing Contact Phone Number

UNDERWRITING INFORMATION
Do you make physical inspections of the properties?

IMPORTANT: Policy requires monthly inspections to all VACANT properties. Inspection reports should be immediate upon property becoming vacant and you secure the location. This report should contain the date the property was secured, receipt for locks being changed and the condition along with pictures of the property at the time of that inspection. These monthly inspection reports are created and maintained by you.

Are vacant properties properly secured? (i.e. Doors locked; no broken windows; windows locked)

IMPORTANT:Policy requires vacant properties are properly secured.

Are vacant properties winterized (i.e. heat left on, pipes drained)?
Do you inspect the interior AND the exterior?
Do you receive written reports in the event another party makes inspections?
How often are inspections made?

IMPORTANT: Policy requires monthly inspections to all VACANT properties.

Do inspections include safety and physical hazards at each location? (i.e. ENTRYWAYS, STEPS, RAILINGS - Loose boards, bricks, stones, hand railing )

Are repairs made promptly to properties where a hazard to the public exists? (i.e. SIDEWALKS - uneven, cracked, tree root growth)

IMPORTANT: Policy requires vacant properties are properly secured.

Is any outside firm contracted to make inspection / manage property?
Please specify the type of firm (Realtor/Broker, Management Firm, etc.)
Please specify name of this firm

How long has company been in property management business?
Will any properties be renovated?
Do you require contractors and subcontractors to provide proof of liability insurance prior to hiring?

PRIOR COVERAGE / LOSS HISTORY
Do you currently have coverage elsewhere?
Please complete the remainder of this section.
Name of Carrier
Limit of Insurance
Annual Premium
Commercial Deductible
Residential Deductible
Commercial Rate
Residential Rate
*Have you had any losses within the past 5 years?
Please list below. If more than one loss, please forward your loss history by upload option below or email/fax.
Date of Loss
Type of Loss
Amount Paid
Status
OpenClosed
Properties Loss History
Maximum file upload size: 5mb.

PROPERTY LIST / PORTFOLIO
* Do you have more than 8 properties to insure?
List of Properties
Maximum file upload size: 5mb.
Please Upload
Please List or Upload
Property Address
City
State
Zip
Insured Value
Dollar amount only (e.g. 75000.00)
Valuation Type
Occupancy
If Occupied, Select Type
RentalLand Contract
Property type
Residence Type

Property Address
City
State
Zip
Insured Value
Dollar amount only (e.g. 75000.00)
Valuation Type
Occupancy
If Occupied, Select Type
RentalLand Contract
Property type
Residence Type

Property Address
City
State
Zip
Insured Value
Dollar amount only (e.g. 75000.00)
Valuation Type
Occupancy
If Occupied, Select Type
RentalLand Contract
Property type
Residence Type

Property Address
City
State
Zip
Insured Value
Dollar amount only (e.g. 75000.00)
Valuation Type
Occupancy
If Occupied, Select Type
RentalLand Contract
Property type
Residence Type

Property Address
City
State
Zip
Insured Value
Dollar amount only (e.g. 75000.00)
Valuation Type
Occupancy
If Occupied, Select Type
RentalLand Contract
Property type
Residence Type

Property Address
City
State
Zip
Insured Value
Dollar amount only (e.g. 75000.00)
Valuation Type
Occupancy
If Occupied, Select Type
RentalLand Contract
Property type
Residence Type

Property Address
City
State
Zip
Insured Value
Dollar amount only (e.g. 75000.00)
Valuation Type
Occupancy
If Occupied, Select Type
RentalLand Contract
Property type
Residence Type

Property Address
City
State
Zip
Insured Value
Dollar amount only (e.g. 75000.00)
Valuation Type
Occupancy
If Occupied, Select Type
RentalLand Contract
Property type
Residence Type

IMPORTANT
This insurance provides single interest only to the named insured. The signed application warrants all information provided on this application is true and factual.

Signed applicant understands that it is their responsibility to read and comprehend the contents of this application, and that any material misrepresentation or omission will invalidate coverage.

THIS IS NOT A POLICY OF INSURANCE. THIS IS AN APPLICATION TO RECEIVE A QUOTE AND PROVIDES NO COVERAGE WHATSOEVER.