Supplement To Acord 125, 126 And 140
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2POLICIES ISSUED BY MIDDLESEX MUTUAL ASSURANCE COMPANY, MIDDLETOWN, CT and HOLYOKE MUTUAL INSURANCE COMPANY IN SALEM, SALEM, MA
VPP® Vacant Property Program
VPP®
Supplement to ACORD 125, 126 and 140
Applicant:
Date:
Prior address if less than two years at current location:
Applicant's Date of Birth:
A. Program Eligibility Questions
Any “YES” response means the account is ineligible
Select Yes or No
1. Is the property in or in the process of being foreclosed?
2. Has the property been vacant for 18 months or longer?
Select Yes or No
3. Is the building undergoing renovations that exceed more than 10% of its insurable value?
Select Yes or No
4. Is any structure in this application NOT locked and fully secured against unauthorized entry, with all windows
and doors intact or boarded up? Note: not applicable if partial vacancy
Select Yes or No
5. Does the property have unrepaired damage, partially constructed, scheduled for demolition, obsolete, or condemned?
Select Yes or No
6. Is the building intended for Condo Assoc, Historic Property, Manufacturing, Industrial or Warehouse/Wholesale use?
Select Yes or No
7. Is the building larger than 25,000 square feet?
Select Yes or No
Any “YES” response means the account is ineligible for liability but may be eligible for property coverage
8. Is there a dock, pier or wharf on the premises?
Select Yes or No
Select Yes or No
9. Other than propane, does the property have an underground fuel storage tank?
10. Is there an outdoor pool or hot tub that is NOT fenced, locked, drained, and covered?
Select Yes or No
11. Is a watch dog kept on the premises?
Select Yes or No
12. Does the property sit on more than 10 acres?
Select Yes or No
B. Water Damage Avoidance
A “NO” response to both Q# 1 and Q# 2 means the account is eligible only for the Basic VPP.
1.
Is the water supply shut off, all systems and appliances drained and anti-freeze added to all standing water?
Select Yes or No
2.
Is there a low temperature alarm device with a telephone dialing feature or water shut-off system installed and
operational in all structures with plumbing?
Select Yes or No
C. Coverage Option Requested
Select Coverage Option
D. Additional Property Information
Select One
Location
Building
Prior Use:
If Commercial, describe prior businesses:
Risk is:
Select one
If, partially vacant indicate (1) Percent of vacancy
%
Describe tenants:
Note: Deductible Minimums - Dwelling $500 & Commercial $1,000
Select One
Location
Building
Prior Use:
If Commercial, describe prior businesses:
Risk is:
Select one
If, partially vacant indicate (1) Percent of vacancy
%
Describe tenants:
Note: Deductible Minimums - Dwelling $500 & Commercial $1,000
Select One
Location
Building
Prior Use:
If Commercial, describe prior businesses:
Risk is:
Select One
If, partially vacant indicate (1) Percent of vacancy
%
Describe tenants:
Note: Deductible Minimums - Dwelling $500 & Commercial $1,000
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