Vacant Building Submission Vacant Application Vacant App Step 1 of 3 33% What Coverages is your client looking for?(Required) Commercial Property Commercial General Liability Deselect AllAgency InformationAgency Name(Required) Agency Name Agency Contact Info(Required) Agent Contact Name Phone Number Email Address Agency Mailing Address(Required) Street Address Address Line 2 City State 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 ZIP Code Insured InformationApplicant Name(Required) Applicant Name Inspection Details Inspection Contact Name Inspection Contact Phone Number Mailing Address Details(Required) Mailing Street Address Mailing Street Address Line 2 Mailing City Mailing State 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 Mailing ZIP / Postal Code Location Address Details(Required) Location Address is Same as Mailing Mailing Street Address Mailing Street Address Line 2 Mailing City Mailing State 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 Mailing ZIP / Postal Code Requested Coverage DetailsRequested Effective Date(Required) MM slash DD slash YYYY Policy Term(Required) 3 Months 6 Months Annual Which property coverages are needed?(Required) Building Personal Property Building Limit DetailsBuilding Limit of InsuranceCause of LossSpecialBasicBroadValuationActual Cash ValueReplacement Cost ValueDeductible$0$500$1,000$2,500$5,000$10,000$25,000Personal Property Limit DetailsPersonal Property Limit of InsuranceCause of LossSpecialBasicBroadValuationActual Cash ValueReplacement Cost ValueDeductible$0$500$1,000$2,500$5,000$10,000$25,000General Liability Limit DetailsGeneral Liability Coverage Limits(Required) $100,000 per occurrence / $200,000 aggregate $300,000 per occurrence / $600,000 aggregate $500,000 per occurrence / $1,000,000 aggregate $1,000,000 per occurrence / $2,000,000 aggregate Eligibility QuestionsWho was the prior carrier?(Required)Have there been any losses in the last 5 years?(Required) Yes No Please describe the loss(es) below:(Required)What was the previous occupancy?(Required)How long has the property been Vacant?(Required)Why is the building currently Vacant?(Required)Square footage of Building:(Required)Please enter a number greater than or equal to 1.Year the Building was Built:(Required)Please enter a number from 1500 to 2050.Age of Roof:(Required)Please enter a number from 1500 to 2050.Protection Class:(Required)12345678910Construction Type:(Required)FrameFire ResistiveWood Frame / LogJoisted Masonry / BlockJoisted MasonryMasonry Non-CombustibleModified Fire ResistiveNon-CombustibleHeavy Timber JoistedSuperior Non-CombustibleSuperior Masonry Non-CombustibleMetal/Plastic SidingConcreteLight Metal / Aluminum SidingsNumber of Stories:(Required)Please enter a number greater than or equal to 1.Are utilities operational water and/or electric?(Required) Yes No How is the building being secured?(Required)What physical condition is the building in?(Required) Excellent Average Poor Is there a pool on the premises? Yes No Is the pool Above or Below Ground? Above Ground Below Ground Is the pool fenced? Yes No RenovationsAre renovations going to take place?(Required) Yes No What is the cost of renovations?Who will be doing the renovations?(Required) Insured Contractor Does the contractor have General Liability coverage in force?(Required) Yes No Will the Named Insured secure Certificates of Insurance?(Required) Yes No Consent I agree to the privacy policy.List Add Remove
