Bader Personal Property Insurance Participation Form
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1
2BADER
Personal Property Insurance Participation Form
Guardian Self Storage-New Windsor
149 Windsor Highway
BADER Op #: 2499-5
New Windsor, NY 12553
845-561-0606
The Lessee may participate in coverage arranged by the storage facility which covers personal property against fire, smoke, explosion,
and windstorm. This coverage will be provided through a licensed Agent. NEITHER THE STORAGE COMPANY NOR THE LEASING
AGENT ARE INSURANCE AGENTS. DIRECT QUESTIONS TO BADER COMPANY - Toll-Free Phone: 888-223-3726 or Fax: 888-
329-2237
LESSEE INFORMATION
Lessee’s Name(s):
______________________________________
Effective Date: _______________
Lessee’s Address:
______________________________________
Unit #: ______
______________________________________
Disc/Cylinder Lock:
YES
NO
City, State, Zip:
___________________, ______________________ _______
Daytime Phone #:
_________________________ Email Address:______________________
(Initial next to “Yes” and check box next to coverage option)
COVERAGE SELECTION
[ ] YES, I AGREE TO PARTICIPATE IN THE TENANT INSURANCE PROGRAM FROM BADER COMPANY,a licensed
insurance agency, and to pay the Monthly Fee when due. I understand that the Monthly Fee includes the premium and
the storage company’s cost of administering the program. A breakdown of the Monthly Fee is specified in the Certificate of
Insurance and Summary of Coverage you will receive. I understand that my failure to pay the Monthly Fee when due will
result in my termination from the program.
Coverage: $2000 Monthly Fee: $9
Coverage: $3000 Monthly Fee: $13
Coverage: $5000 Monthly Fee: $21
The Commercial Inland Marine Leased Premises Property Coverage Program provides coverage for your personal property while it is
stored in the storage facility. The program is underwritten through The Pennsylvania Manufacturers’ Association Insurance Company
(PMAIC) and coverage is subject to their underwriting requirements. Coverage is not “all risk” and flood coverage is not provided.
Property stored in open lots or non-fully enclosed, secured garages or storage units is not eligible. This participation form contains only
a general description of coverage and does not constitute an insurance contract. Coverage for your stored property will be provided
under the storage facility’s policy and you will be provided a Certificate of Property Insurance and a Summary of Coverage by the
program administrator listed below. By signing below, I acknowledge that I understand the coverage I have agreed to purchase will
terminate if the Monthly Fee is more than 30 days delinquent under the terms of my Summary of Coverage. I authorize re-instatement
of said coverage under the same terms and conditions without completing a new participation form under the following circumstances:
1. I am still renting the same unit shown on my original participation enrollment form. 2. I understand that I will NOT be charged a
Monthly Fee for the period during which coverage had been terminated and that there is NO COVERAGE for the period during which
coverage had been terminated. 3. There is no loss or damage to any property stored in this unit. If there was damage to, or loss of, any
property stored in the unit that occurred after the coverage terminated for non-payment, I understand that the coverage will not apply to
this loss and I agree that I will not file a claim for said loss or damage with the insurance company or storage facility.
Signature(s):
Date:
To access a copy of the certificate of property insurance, go to:
Or call 1-888-223-3726 and select #1, #1
[
]
NO, I HAVE PROPERTY INSURANCE OF THE TYPE CHECKED BELOW.
A copy of my policy Declarations page
is attached as evidence of coverage. I agree to keep coverage in force during the term of my lease.
Insurance Company Name:
Homeowners
Renters
Business
Owners
Other:
Policy #:
Limit $:
Effective Date:
Term:
Signature(s):
Date:
Agent: Joshua M. Nicholson CA License: I051767
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