Vacant Dwelling Application Form
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1
2VACANT DWELLING APPLICATION FORM
THE ANSWERS TO THESE QUESTIONS FORM PART OF AN APPLICATION FOR INSURANCE ONLY. NOTHING IN THIS APPLICATION
SHALL BE DEEMED AN AGREEMENT TO PROVIDE INSURANCE AND UNDERWRITERS MAY DECLINE TO OFFER COVERAGE OR
OFFER COVERAGE ON TERMS THAT DIFFER FROM THE COVERAGE SOUGHT BY THE APPLICANT.
GENERAL DETAILS
Name and Mailing Address of Applicant:
State
Zip code
Telephone
Email
Address of Property to be Insured:
State
Zip code
Name and Address of Retail Broker:
State
Zip code
CONTACT DETAILS
Contact Name
Telephone
Email
COVERAGE AND PROPERTY DETAILS
1. What type of Cover would you like?
Property
Package
2. Period of Insurance required:
Three months
Six months
Nine months
Annual
3. Total Value of building(s) to be insured:
4. Premises Liability limits: $25,000
$50,000
$100,000
$300,000
$500,000
$1,000,000
5. Requested Effective Date:
6. Construction
Type:
Fire Resistive
Frame
Masonry non combustible
Other
7. Protection Class:
7a. Total Sq Footage of building to be insured including outbuildings:
8. Age of Building or complete building upgrade in?
0-25 Years
26-50 Years
Over 50 Years
(This includes plumbing, electric, roof)
9. Is Vandalism and Malicious Mischief cover required?
Yes
No
10. Are there any other Structures to be insured?
Yes
No
11. Value of Other Structure(s):
Please provide a brief description:
12. All Other Perils Deductible (excluding Wind Peril):
$500
$1,000
$2,500
$5,000
$7,500
$10,000
$25,000
13. Wind and Hail Deductible per occurrence:
$500
$1,000
$2,500
$5,000
$7,500
$10,000
$25,000
14. How often is the building to be insured inspected by the applicant or the applicant’s representative? Daily
Weekly
Monthly
Other
15. Which Utilities are operational
Electricity only
Water only
Electricity & Water
None
16. Is there a fully functional Central Station Burglar Alarm with active monitoring contact?
Yes
No
17. Have there been any insured or uninsured losses or claims at the property to be insured?
Yes
No
Describe all prior losses or claims including the date, the nature or occurrence, the status, the amount, and whether the damage has been
repaired:
ATR – 17 Dwelling Application
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