1-4 Tenant Occupied Dwelling Application Form
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31-4 Family Tenant Occupied Dwelling Application
Required Information from Acord Forms 125, 126 & 140
Agency Information
Agency Name: ___________________________________ Producer Name/Contact: __________________________________
Agency Address: _________________________________________________________________________________________
Phone#: _______________________________
E-mail: ________________________________________________________
General Information
*
Denotes Required Fields
*
Name of Insured:
_____________________________________________________________________
*
Business Entity(choose one):
Individual ______
Partnership ______
Joint Venture ______
Corporation ______
Trust ______
Limited Liability Co. ______
*
Business Description: __________________________________________________________________________________
*
Policy Effective Date:
________________________
* Policy Expiration Date: ______________________
Location Information - * Denotes Required Fields
* Building #1
*
Address Line 1: ______________________________________________________________
Address Line 2: ______________________________________________________________
* City/State/Zip:_______________________________________________________________
* PPC/Fire District Code:______________________________________
*
Number of families: ______
*
Year Built:_______
*
# Stories:______
*
Total Square Footage: _______
*
Construction Type (choose one):
Frame ______
Joint Masonry/Brick ______
*
Wiring Year Updated: ______________
*
Plumbing Year Updated: ______________
*
Roofing Year Updated: _____________
*
Heating Year Updated: _______________
Cause of Loss/Deductible -
*
Denotes Required Fields
*
Cause of Loss (choose one):
Basic ______
Special Excluding Theft ______
Broad ______
Special Including Theft ______
*
Deductible Amt (choose one):
$500______
$1,000______
$2,500______
$5,000______
*Basic Group II Symbol (choose one):
Ordinary Construction______
Wind Resistive Construction______
Semi-Wind Resistive Construction______
Building Coverage -
*
Denotes Required Fields
*
Limit: __________________________
- If there is a detached garage, please include this limit in your building limit.
*Valuation (choose one): Replacement Cost ______
Actual Cash Value______
Agreed Amount______
*Coinsurance (choose one):
80% ______
90% ______
100% ______
*
Does this building have an Exterior Insulation Finishing System (EIFS) installed?
YES or NO
* Rental Income Coverage Extra Expense - Excluded or Included? If Included, provide Limit: ______________________
* General Liability - Each Occurrence Limit (choose one):
$300,000 ______
$500,000 ______
$1,000,000 ______
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Parent category: Business