Vacant Dwelling Application Form (Page 2 of 2) in pdf

COVERAGE AND PROPERTY DETAILS (continued)

18. Identify all mortgagees, lien holders and additional loss payees (if any, including account numbers and outstanding amounts):

19. If required, please enter below details of Additional Insured:

ELIGIBILITY QUESTIONS

20. In which State is the property to be insured:

21. Please confirm the type of property to be insured:

Residential

Commercial

Farm

Other

22. Please enter the period the property has been vacant:

0-6 months

7-13 months

14+ months

23. Has the property to be insured been continuously covered by a policy of property insurance since becoming vacant?

Yes

24. Is the building(s) to be insured secured against unauthorized entry?

Yes

25. Has the applicant had any policy of property insurance cancelled or non-renewed in the past

3 (three) years for reasons other than vacancy? (Not applicable to risks located in MO. For MO

risks please select 'No'.):

26. Is the applicant currently involved in bankruptcy proceedings?

27. Is the property to be insured subject to mortgage foreclosure proceedings or tax liens?

Yes

28. Has the property to be insured been condemned or is it scheduled for demolition?

29. Existing damage to building(s) to be insured?

30. Is the property to be insured subject to more than two mortgages or other encumbrances?

31. Has the applicant been convicted of the crimes of arson or insurance fraud?

32. Is the property to be insured undergoing any renovation or construction work of any kind, or is any such work due to commence while

insurance is in effect?

Yes

If the answer above is “yes” please answer the following question

33. Is the renovation or construction work (i) being performed by a contractor or owner where project costs exceed $250,000; or (ii) involve

structural work or structural repairs being performed by any person?

Yes

SUPPLEMENTARY RENOVATION QUESTIONS (WHERE APPLICABLE)

34. Estimated Renovation or Construction Work Project Costs:

35. Description of Renovation or Construction Work:

36. Is Work being undertaken by a Contractor? Yes

37. What CGL Limit carried by the Contractor? 300k

500k

DECLARATION

THE ANSWERS GIVEN IN THIS APPLICATION ARE CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT

THESE ANSWERS WILL FORM PART OF A POLICY THAT IS SUBSEQUENTLY OFFERED. I ALSO UNDERSTAND THAT

ANY FALSE STATEMENT MAY VOID THE INSURANCE IN ITS ENTIRETY OR RESULT IN A CLAIM BEING DENIED.

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON

FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR

THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A

FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND (NY:

SUBSTANTIAL) CIVIL PENALTIES. (NOT APPLICABLE IN CO, HI, NE, OH, OK, OR, VT FOR WHICH SEE ATTACHED). IN

DC, LA, ME, TN AND VA, INSURANCE BENEFITS MAY ALSO BE DENIED.

Applicant’s Signature

Retail Broker’s Signature

Date

ATR – 17 Dwelling Application

Page 2 of 2

Vacant Dwelling Application Form Page 2

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