CompanyThis field is for validation purposes and should be left unchanged.Applicant InformationWhat Entity type owns this property?(Required) Individual Corporation LLC Trust Other Applicant's Full Name:(Required) First Last Applicant Entity Name:(Required)Applicant Owner's Name:(Required) First Last Date of Birth:(Required) MM slash DD slash YYYY Date Applicant Began Operations:(Required) MM slash DD slash YYYY Date Trust was Formed:(Required) MM slash DD slash YYYY Trust Owner's Date of Birth:(Required) MM slash DD slash YYYY Gender:(Required) Male Female Trust Owner's Gender:(Required) Male Female Marital Status:(Required) Single Married Divorced Widowed Trust Owner's Marital Status:(Required) Single Married Divorced Widowed Home Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Trust Owner's Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Business Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is home address same as mailing address?(Required) Yes No Is owner's address same as mailing address?(Required) Yes No Is business address same as mailing address?(Required) Yes No Mailing Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number:(Required)Email Address:(Required) Inspection Contact:(Required)Applicant Occupation:(Required)Trust Owner's Occupation:(Required)Why was the trust formed?(Required)(e.g., Tax Purposes, Real Estate Investments, Asset Protection, etc.)If the trust has been engaged in any form of business, please explain:(Required)(N/A if not applicable)If the Trust owns any other properties, please list here:(Required)(N/A if not applicable)Is the Trust a "Land Trust"?(Required)(Hint: A Land Trust allows you to transfer ownership (title to real property) to a legal entity that holds the land for the benefit of a beneficiary) Yes No Please list the beneficiaries of the Trust:(Required)Full NameDOBRelationship to Trust Owner Add RemoveIs the property deeded to the Trust?(Required) Yes No If so, confirm if the Owner of the Property be listed as the Trust, or the Trust's Owner?(Required) Owner is the Trust Owner is the Trust's Owner Property InformationRental Property Address:(Required) Street Address City State / Province / Region ZIP / Postal Code Type of Property:(Required) Single-Family Multi-Family Condo Townhouse Other Number of Units:(Required)Please enter a number from 1 to 99.Year Built:(Required)Construction Type:(Required) Frame Brick Stucco Other Square Footage:(Required)Date the applicant purchased this property?(Required)Purchase Price:(Required)Has the property been condemned or ordered uninhabitable by any authority?(Required) Yes No If yes, please explain:(Required)Is the applicant a bank, lender, or financial institution?(Required) Yes No If yes, please provide the name:(Required)Is the property being used by the applicant or insured in the commission of a felony, including arson, fraud, or other insurance related offenses, or used in violation of law that increases risk to the property?(Required) Yes No If yes, please explain situation:(Required)Is this a farm/winery risk?(Required) Yes No Is the property currently insured?(Required) Yes No Insurance Carrier:(Required)Expiration Date:(Required) MM slash DD slash YYYY Is the property used to store flammable or explosive materials in violation of the law?(Required) Yes No If yes, please explain:(Required)Are flammable or explosive materials stored?(Required) Yes No If yes, please describe:(Required)Are there any missing, expired, or improperly stored fire extinguishers?(Required) Yes No If yes, please describe:(Required)Do you have a mortgage loan for this property?(Required) Yes No If yes, please provide lender name, loan number, and contact number:(Required)Has the FAIR Plan ever refused coverage, cancelled coverage, or non-renewed coverage at this location (other than for non-payment of premium)?(Required) Yes No If yes, please explain:(Required)Roof Type:(Required)Number of Stories:(Required)Please enter a number from 1 to 99.Number of Bedrooms:(Required)Number of Bathrooms:(Required)What kind of wiring do you have in the home?(Required) Copper Aluminum Knob & Tube If Aluminum/Knob & Tube, do you plan on replacing the wiring in an upcoming renovation?(Required) Yes No What do your electrical systems consist of?(Required)Hint: Fuses are more common in older homes Electrical Panels Fuses Please describe your primary heating system:(Required)Furnace, radiant floor heating, etc.What primary door locks do entrances/exits have?(Required)Hint: A spring lock is a mechanism that retracts the lock with the turn of the knob, usually used for interior/bedroom doors. A deadbolt lock is a lock that can only be applied inside manually or outside with a key, that extends a bolt into the door frame. Deadbolt locks Spring locks Both Are smoke detectors local or central?(Required)Local alarms flash and sound, alerting individuals in that specific location. A central alarm will do the above, and notify a central station that can then dispatch authorities. Local Central No Alarm Are burglar/security alarms local or central?(Required)Local alarms flash and sound, alerting individuals in that specific location. A central alarm will do the above, and notify a central station that can then dispatch authorities. Local Central No Alarm Any recent renovations or updates?(Required) Yes No If yes, provide details such as renovation type and month/year completed:(Required)Renovation/Construction DetailsIs this property currently under renovation or construction?(Required) Yes No Is the property locked and secured during non-working hours?(Required) Yes No Is the property locked and secured during non-working hours?(Required) Yes No Is there lighting on property?(Required)(Outdoor lighting not dependent on property power) Yes No Is there a 24 hour guard on premises?(Required) Yes No Is this a gated/guarded community?(Required)(You need a gate opener/key to get into community) Yes No Any other security measures not mentioned above?Are you using a licensed contractor for the renovations/construction?(Required)(You hired a contractor to oversee and manage the renovation) Yes No (a) Name of Contractor:(Required)(b) License Number:(Required)(c) Does the Contractor have General Liability coverage in place?(Required) Yes No (d) If so, what is their Limit of General Liability?(Required)Are You acting as the contractor for the renovations/construction?(Required)(You are overseeing the project instead of hiring a contractor to manage it) Yes No (a) If you are acting as a contractor, please describe your years of experience, job types worked on, etc.(Required)(b) Do You have General Liability coverage in place?(Required) Yes No (c) If so, what is your Limit of General Liability?(Required)Are you using subcontractors?(Required)(Specialist for a job like plumbing, electrical work, etc.) Yes No If subcontractors are used, are they licensed?(Required) Yes No Do you obtain evidence of insurance from subcontractors?(Required) Yes No If any contractor/subcontractors are unlicensed, please describe their years of experience, job types worked on, etc.(Required)Renovation/Construction Start Date:(Required) MM slash DD slash YYYY Renovation/Construction End Date:(Required)Estimate if unsure MM slash DD slash YYYY Current percentage of completion:(Required)Describe in full detail all of the current construction/renovations:(Required)Occupancy & Rental DetailsIs the property currently rented?(Required) Yes No Vacant Under Renovation Is the property rented to (or will be rented to):(Required) Long-term tenants Short-term tenants Section 8 tenants Other Do you have a current property manager?(Required) Yes No If yes, name/contact:(Required)Monthly Rental Income:(Required)How long has the applicant owned this rental property?(Required)Does or will the applicant live at this property?(Required) Yes No Safety and ProtectionIs there a functioning smoke alarm in each unit?(Required) Yes No Are there carbon monoxide detectors?(Required) Yes No Fire extinguishers on-site?(Required) Yes No Is the property equipped with a security system?(Required) Yes No Is there a swimming pool on the property?(Required) Yes No If yes, is it fenced/secured?(Required) Yes No Insurance Coverage NeedsDesired Dwelling Coverage Limit:(Required)Liability Coverage Limit:(Required)Loss of Rental Income Coverage?(Required) Yes No Flood Insurance Needed?(Required) Yes No Not Sure Earthquake Insurance Needed?(Required) Yes No Not Sure Deductible Preference:(Required)Claims HistoryAny prior property insurance claims in the last 5 years?(Required) Yes No If yes, describe each claim (date, amount, type of loss):(Required)Additional PropertiesDo you own additional properties to insure?(Required) Yes No If yes, provide addresses and basic info below:(Required)Attach additional documentation (Optional):Max. file size: 50 MB. Additional InformationUse the space below to provide any other relevant information or special considerations that may affect your insurance policy. Δ
