1-4 Tenant Occupied Dwelling Application Form Page 2
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3Optional Coverages -
*
Denotes Required Fields
A separate Equipment Breakdown deductible of $2500 will apply in all states (excluding Connecticut) if the
all perils deductible is less than $2500 and property class code 0532, 0542, or 0545 has been selected.
*
Equipment Breakdown - YES or NO
*
Hired and Non Owned - YES or NO
* Ordinance or Law - YES or NO
If YES, Please provide Building Ordinance or Law Cost Limits (Coverage A is Included in Building Coverage):
*
(Cov B) Demolition Cost Limit: ________________
*
(Cov C) Increased Cost of Construction Limit: _______________
General Information -
*
Denotes Required Fields
*
Is this a new venture? Yes or No
*
Year business established/acquired: ___________
Insured's prior carrier and loss history information
(This section is required to bind a policy, with the exception of new ventures.)
* Prior Carrier Name:_________________________________________ * Effect Date:_________
* Exp Date:________
Policy Number:_________________________________
Premium:__________________
* # of Losses: _________
General Questionnaire -
*
Denotes Required Fields
General Questions - YES or NO - Please explain All "Yes" Responses
*________1.
Is applicant in receivership/trust?
*________2.
Any exposure to flammables, explosives, chemicals?
*________3.
Any policy or coverage declined/cancelled/non-renewed during prior 3 years? (excluding non-pay)
*________4.
Any uncorrected fire code violations?
*________5.
Any bankruptcies, tax or credit liens against the applicant in the past 5 years?
*________6.
During the Last Five Years, has any Applicant been Indicted for or Convicted of any degree of the crime of fraud,
Bribery, Arson Or any other Arson-Related crime in Connection with this or any other property?( Failure to disclose the existence of
an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment).
*________7.
Any premises undergoing renovations?
Explain: _____________________________________________________________________________________
General Liability Questions – YES or NO - Please explain All "Yes" Responses
*________1.
Do/have past, present or discontinued operations involve(d) storing, treating, discharging,
applying, disposing, or transporting of hazardous material?
*________2.
Machinery or equipment loaned or rented to others?
*________3.
Any watercraft, docks, floats owned, hired or leased?
*________4.
Any parking facilities owned/rented?
*________5.
Any indoor parking facility?
*________6.
Is there a swimming pool on the premises?
*________7.
Any structural alterations contemplated?
*________8.
Any demolition exposure contemplated?
*________9.
Any day care facilities operated or controlled?
*________10.
Have any crimes occurred or been attempted on your premises within the last 3 years?
Explain: _____________________________________________________________________________________
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