Apartment Application

This is a BOP Application - We must have property to value information.

EPLI Available.

(Please request application from (800) 400-3276)

Please complete the form below and click the submit button to complete the application.

Fields marked with (*) are required fields.

Application works only in Microsoft Internet Explorer - Compatability View and Mozilla Firefox, does not work in Google Chrome

Agent Information

Agency*

Agent Name*

Phone*

Fax*

Agent E-Mail Address*

Would you like the quote sent* Fax Email

Policy Information

Proposed Effective Date*

Application Information

Business Name*

Type of Business*

Owner(s) Name*

Legal Entity*

Mailing Address*

Telephone (required to reserve account): (Area Code, Number & Ext.)*

Current / Prior Carrier: (Include Company Name, Coverage Types, Line of Business and Dates.)*

Has policy been cancelled or non-renewed in past 3 years? If yes, please describe* Yes No

If yes, please describe

Any claims in the last 3 years? (Package Only)* Yes No

If yes, please explain and include : Description, Date, Amount Paid, and What has been done since to prevent a reoccurence?

Fields marked with (*) are required fields.

Nature of Business

Apartment:*

Apartment with Mercantile*

Any Section 8 Tenants?* Yes No

Condo or HOA*

HOA Annual Fees/Receipts*

Apartment Annual Receipts*

Any pools*

If so, is the pool fenced?*

If there is a pool, does it have a slide or diving boards?*

Are there any balconies?* Yes No

Are BBQ's allowed to be used on the balconies or rooftops?* Yes No

Are there any Fireplaces?* Yes No

Any Playground Equipment*

Location

Location Address: (Include County & Zip)*

Year Built*

Please List Building Improvements: Building updates required for all buildings 25 years or older

Wiring Year

Roofing Year

Plumbing Year

Heating Year

Years in Business*

Years of Experience*

Square feet occupied by the insured:*

Number of units*

Number of stories*

Number of Elevetors*

Number of buildings*

Total Square footage*

Building 1*

Building 2

Building 3

Building 4

Building 5

Construction type*

Smoke or Fire Alarms?* Yes No

Are the alarms hard wired or battery operated?*

Sprinklers?* Yes No

If yes

Parking Area*

If Underground, square footage of parking area

Fields marked with (*) are required fields.

Additional Interests

Mortgagee*

Management Company*

Manager*

What is your target premium?*

Payment Plan Desired*

Additional Comments

Any person who knowingly and with intent to defraud any insurance company or another person files an application for Insurance or statement of claim 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 civil penalties. The undersigned is an authorized representative of the applicant and represents that reasonable enquiry has been made to obtain the answers to questions on this application. He/She represents that the answers are true, correct and complete to the best of his/her knowledge.

Applicant Signature/Print Name

Agent/Producer Signature/Print Name

Attachments

Please attach any additional documents needed for your submission, click the folder below to select one or more files.

Your application has not been submitted yet. Please review all of your answers below and

click the submit button at the bottom of this page to complete your application

Agency

Agent Name

Phone

Fax

Email Address

Would you like the quote sent

Proposed Effective Date

Business Name

Type of Business

Owner(s) Name

Legal Entity

Mailing Address

Telephone (required to reserve account): (Area Code, Number & Ext.)

Current / Prior Carrier: (Include Company Name, Coverage Types, Line of Business and Dates.)

Has policy been cancelled or non-renewed in past 3 years? If yes, please describe

If yes, please describe

Any claims in the last 3 years? (Package Only)

If yes, please explain and include : Description Date Amount Paid What has been done since to prevent a reoccurence?

Apartment:

Apartment with Mercantile

Condo or HOA

HOA Annual Fees/Receipts

Apartment Annual Receipts

Any pools

Any Playground Equipment

Location Address: (Include County & Zip)

Year Built

Wiring Year

Roofing Year

Plumbing Year

Heating Year

Years in Business

Years of Experience

Square feet occupied by the insured:

Number of units

Number of stories

Number of Elevetors

Number of buildings

Total Square footage

Building 1

Building 2

Building 3

Building 4

Building 5

Construction type

Sprinklers?

If yes

Parking Area

If Underground, square footage of parking area

GL Limits

Building Limits

Coinsurance

Property Deductible

A/I's

D&O Limit

Hired/Non-Owned Auto

Business Income Extension if over 12 months

Sewer/Drain Backup Limit

Building Glass

Any Business Personal Property

Ordinance or Law A/B/C

Commercial Umbrella Coverage? Please Send Accord

Workers Compensation Coverage? Please See Below To Get Quote

Technology & Misc. E&O, D&O, EPL This is a required field. This field must be completed to continue. Contact Us For Qualification & Application For Markets, Grocery Stores & Restaurants.

Mortgagee

Management Company

Manager

What is your target premium?

Payment Plan Desired

Additional Comments

Applicant Signature/Print Name

Agent/Producer Signature/Print Name

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