Long-Term Residential & Rental Form

Long-Term Residential & Rental

Long-Term Residential & Rental Information

Please complete the information below to request a Long-Term Residential & Rental insurance quote. Fields marked with * are required.

GENERAL APPLICANT & PROPERTY INFORMATION

Applicant and property details

Named Insured / Legal Entity *

DBA (Trade Name)

FEIN / Tax ID

Property Address / Risk Location *

Contact Name & Title *

Phone *

Email *

Year Building Built *

Total Square Footage *

# of Stories *

# of Basements *

REQUESTED PROPERTY COVERAGE LIMITS & VALUATION

Coverage category, requested limit, valuation method and deductible

Coverage Category	Requested Limit ($)	Valuation Method	Deductible ($)
Building Limit		Replacement Cost ACV
Business Personal Property (BPP)		Replacement Cost ACV
Business Income / Rental Value		Actual Loss Sustained ALS
Tenant Improvements & Betterments		Replacement Cost ACV

CONSTRUCTION TYPE & BUILDING SYSTEM UPDATES

Construction classification and major building systems

ISO Construction Class

Frame (Class 1) Joisted Masonry (Class 2) Non-Combustible (Class 3) Masonry Non-Combustible (Class 4) Fire Resistive (Class 6)

Building System	Year Last Updated	Type / System Details
Roofing System		Roofing System Type / System Details
Electrical Wiring		Electrical Wiring Type / System Details
Plumbing System		Plumbing System Type / System Details
Heating / HVAC		Heating / HVAC Type / System Details

OCCUPANCY DETAILS & PROTECTIVE SAFEGUARDS ASSESSMENT

Protective safeguards & physical risk assessment

Protective Safeguards & Physical Risk Assessment	Yes	No
Is the building 100% equipped with an operational automatic fire sprinkler system?
Is there a 24/7 central-station monitored fire alarm system operational?
Is there a 24/7 central-station monitored burglar alarm / security camera system?
Is the building vacant or unoccupied by more than 30% of total square footage?
Is aluminum wiring, knob-and-tube wiring, or fuse boxes present anywhere in the facility?
Are commercial fire extinguishers installed, inspected, and tagged annually?
Are there high-hazard tenant operations present (e.g., auto repair, woodworking, chemical storage)?
Do tenant leases require tenants to carry General Liability & name you as Additional Insured?

TENANT SCHEDULE & OCCUPANCY BREAKDOWN

Tenant business and occupancy details

Unit / Suite	Tenant Business Name	Nature of Operations	Sq Ft Occupied	COI on File?
1				Y N
2				Y N
3				Y N

PROPERTY LOSS HISTORY & PRIOR CLAIMS (PAST 3 YEARS)

Prior property losses, claims and non-renewal history

Has the property had any losses, water damage, or fire claims in the past 3 years?

YES NO

Has any carrier non-renewed property coverage?

YES NO

If YES to any claims, provide date of loss, cause (water, fire, theft, wind), amount paid, and corrective measures taken:

COMMERCIAL PROPERTY FRAUD WARNING & APPLICANT ACKNOWLEDGEMENT:

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing 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. The undersigned applicant declares that all building, construction, and tenant information provided herein is true, accurate, and complete.

Applicant / Property Owner Signature *

Printed Name & Title *

Date *

Please enter date as MM/DD/YYYY.

Please review your information before submitting the form.