1-4 Tenant Occupied Dwelling Application Form Page 3
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3Nature of Business Questions – YES or NO - Please explain All "Yes" Responses
*________1.
Do any of the premises LACK an adequate secondary means of egress?
*________2.
Are any of the premises occupied by assisted living, foster care, halfway house, homeless shelter,
student housing, or a rehabilitation center?
*________3.
Do any of the premises have more than 25% of the tenants on subsidized housing assistance?
*________4.
Are any of the premises seasonal?
*________5.
Do any of the locations have defective sidewalks?
*________6.
Are any of the units vacant?
Explain: ____________________________________________________________________________________
Additional Insureds/Interests
* Additional Insured Type – (Choose One):
Designated Person or Organization – CG 20 26 ______
Lessor of Leased Equipment – CG 20 28 ______
Managers or Lessors of Premises (LandLord) ______
Mortgagee, Assignee, or Receiver to Premises – CG 20 18 ______
State or Political Subdivisions – Permits Relating to Premises – CG 20 13 ______
Loss Payable Provisions – Contract of Sale ______
- Lender’s Loss Payable ______
- Loss Payable ______
*
Entity Type (choose one):
Individual ______
Other ______
*
Additional Insured Name: __________________________________________________________
*
Address Line 1: ____________________________________________________________________
Address Line 2:____________________________________________________________________
*
City/State/Zip:___________________________________________________________________
Billing and Payment
Billing Plan (choose one):
Direct Bill ______
Agency Bill ______
Payment Plan (choose one):
Full Pay _____
(Note: If you choose not to pay the entire amount, a $10.00 service charge will be included on each payment)
3-Pay 30% Down-2 Installments______
4-Pay 25% Down-3 Installments______
6-Pay 25% Down-5 Installments______
*10-Pay 10% Down-9 Installments______
*10-Pay 15% Down-9 Installments______ *10-Pay 25% Down-9 Installments_____
(* Minimum Premium for 10 pay plan is $2,001)
We recommend that you collect at least the Down Payment from the Insured upon your request to Bind Coverage. It
is the Broker’s responsibility for any Earned Premium and If the Insured does not pay, this Earned Premium will be
deducted from the Broker’s Commission.
*Insured Mailing Address -
Name:
______________________________________________________________
Address 1:
_______________________________________________________
Address 2:
_______________________________________________________
City/State/Zip: ________________________________________________________
Inspection Contact Information -
*
Denotes Required Fields
* Inspection Contact Name: _____________________________________ * Inspection Phone#:_____________________
* Relationship to Insured (choose one):
Owner/Principal ______
Employee ______
Other __________
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