Rental Supplement Form - Phipps Insurance Agency printable pdf download

Rental Supplement Form - Phipps Insurance Agency

Rental Property Supplemental Information

Basic Information

Agency Name & Code: _____________________________________ Applicant Name: _________________________________

Property Location: ____________________________________________________________ Policy #______________________

Underwriting Information

Please provide additional information for any “yes” response in the “Additional Information” section.

YES

1. Are kerosene or portable heaters used in the dwelling? ………………………………………….

2. Is the dwelling occupied as a fraternity, sorority, student housing or similar occupancy? …….

3. Is the dwelling occupied as a rooming house or boarding house? ………………………………

4. Does the property contain working smoke detectors and carbon monoxide detectors? ………

5. Have any full time students executed a lease agreement? ……………………………………….

If “Yes”, how many lease agreements are there for this property: __________

6. Is the dwelling attached to or adjacent to a vacant dwelling? …………………………………….

7. Do the applicants or tenants own, keep or shelter any of the following breeds: Akita, Chow,

Doberman , Presa Canario, American Bulldog, German Shepherd, Rottweiler, Mastiff,

Staffordshire Bull Terrier, Pit Bull Terrier, Wolf Dog or any mixture of these breeds? ………

Landlord Information

1. How long have you been a landlord? _______________________________________________________________

2. Do you employ a property manager or do you manage the property yourself? _______________________________

3. If you live elsewhere, how often do you personally visit the property? ____________________________________

Additional Information / Remarks

I certify that the above information is accurate and complete to the best of my knowledge and belief.

_________________________________________________________________

_______________________

Applicant’s Signature

Date

C163 (08-12)

The Commerce Insurance Company │ Citation Insurance Company

211 Main Street, Webster, MA 01570 │ 508-943-9000 │

Rental Supplement Form - Phipps Insurance Agency