Apartment (Mixed Use) Insurance Quote Request Form (Page 2 of 4) in pdf

Apartment (Mixed Use) Insurance Quote Request Form Page 2

*Any Claims in Last 3 Years, please provide details:

__________________________________________________________________________________________

*100% Sprinklered: Y / N

*Liability Limits: ____________________________________

Other Coverages

*Number of Fenced Pools: ________________________

*Water Back-up/Sump Pump: $_______________________

*Hired & Non-Owned Auto Liability: Y / N. Please provide a schedule of drivers and their Licenses

*Building Ordinance or Law: _________________________max: 20% Building Coverage

*Money & Securities $______________

*Employee Dishonesty:

# of Employees: _______Coverage$ __________Locations: __________________

*24 Month Business Income?: Y / N

*Equipment Breakdown?: Y / N

Underwriting Questions:

*Has there been more than one paid claim at this location in the last 3 years? Y / N

*Located within 1000 feet of a brush area or shoreline? Y / N

*Are there any pools not completely fenced off from all living units? Y / N

*Located on a slope of over 20 degrees? Y / N

*Building(s) have wood shake roof? Y / N

*Building(s) have electrical fuses, knob and tube or aluminum wiring? Y / N

*Building(s) in the course of construction or major renovations? Y / N

*Does spacing between bars on any exterior railings exceed 6 inches? Y / N

*Prior construction defect allegations? Y / N

*Daycare facilities? Y / N

Apartment (Mixed Use) Insurance Quote Request Form Page 2