Section 1 of 7

Applicant Information

Basic details about the named insured and the policy being requested.

Any person who knowingly files an application containing materially false or misleading information commits a fraudulent insurance act subject to criminal and civil penalties.

First Named Insured *

Mailing Address *

City *

State *

ZIP Code *

Contact Phone *

Contact Email

Organization Type

Requested Effective Date *

Expiration of Existing Coverage

Prior Coverage History

Policy Declined, Cancelled, or Non-Renewed in Prior 3 Years?

Yes

No

If Yes, Explain

Bankruptcies or Tax Credit Liens in Prior 5 Years?

Yes

No

Any Applicant Convicted of Arson in Past 10 Years?

Yes

No

Section 2 of 7

Coverage Details

Specify the coverages and deductibles requested.

Coverages Requested

Type of Coverage *

Valuation Basis *

Coinsurance % *

General Liability Requested?

Yes

No

Deductibles

AOP Deductible *

Wind / Hail Deductible

Additional Interests

Mortgagees, lien holders, loss payees, additional named insureds.

Section 3 of 7

Schedule of Values

Enter each building/location. Total TIV calculates automatically.

Any Locations Less Than 200 ft. Apart?

Yes

No

Square Footage Type

Gross

Net Leasable

#	Street Address *	City *	St	ZIP	County	#Bldgs	Yr Built	Roof Yr	Real Prop ($)*	Pers Prop ($)	BI/Rent ($)	Total TIV	#Units	Sq Ft	%Occ
TOTALS									$0	$0	$0	$0	0	0

Section 4 of 7

Building Details

Construction and structural characteristics.

Construction

ISO Construction Type *

Construction Quality

Exterior Wall / Cladding

EIFS Present?

Yes

No

Basement

ISO Protection Class *

Roof

Roof Shape *

Type of Roof Covering *

Roof Anchorage

Flood Zone

Within 1,000 ft. of Saltwater?

Yes

No

Mechanical Systems

Type of Wiring *

Type of Plumbing *

% Hard-Wired Smoke Detectors

% Sprinklered

Renovations

Describe Any Gut Rehabs (Location No., Year, Extent)

Section 5 of 7

Property Conditions

Answer all questions. Used by the underwriter to assess risk.

Occupancy & Operations

Electrical & Heating

Safety Equipment & Amenities

Special Conditions

Unrepaired Damage from a Recent Loss?

Yes

No

Describe Extent of Damage

Building on a Historical Register?

Yes

No

Insurance Company Recommendation Outstanding?

Yes

No

Community-Owned Electric, Water, Dams, or Septic?

Yes

No

Mold / Decay / Collapse

List Any Mold, Hidden Decay, or Collapse Losses Paid or Reported

Section 6 of 7

Loss History

Minimum 3 years required, 5 years preferred. This information is warranted.

Applicant Would NOT Be Aware of All Losses (Prior 5 Yrs)?

Yes — Explain

No

Date of Loss	Location	Cause	Incurred ($)	Deductible ($)	Status

Additional Comments

Section 7 of 7

Review & Submit

Review your answers, certify, then submit.

Fraud Warning: Any person who knowingly and with intent to defraud any insurance company files an application containing materially false information commits a fraudulent insurance act, which is a crime subject to criminal and civil penalties.

Certification & Signature

I certify that the information in this application is true and correct to the best of my knowledge, and that I have not deleted or altered any questions herein. I agree this information shall form the basis of the contract should a policy be issued.

Applicant Signature (Full Name) *

Date *

Contact for Inspection — Name & Phone

Applicant Information

Prior Coverage History

Coverage Details

Coverages Requested

Deductibles

Additional Interests

Schedule of Values

Building Details

Construction

Roof

Mechanical Systems

Renovations

Property Conditions

Occupancy & Operations

Electrical & Heating

Safety Equipment & Amenities

Special Conditions

Mold / Decay / Collapse

Loss History

Review & Submit

Certification & Signature

Application Submitted!