Building Owners Commercial Property Insurance "*" indicates required fields CompanyThis field is for validation purposes and should be left unchanged.Date of ApplicationEffective or Inception date of new policy:Insureds Name on Title*Mailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Contact InformationContact Name:Cell phone numberEmail Address* Losses adjusted with and Payable To:Historical InformationPrior Carrier NamePolicy Period Effective date MM slash DD slash YYYY Policy Period Expiration Date MM slash DD slash YYYY Premium Amount$*# Loss or Claim HistoryCancellation or Non-Renewal DateReason for Cancellation or Non-RenewalCurrent Agent on RecordTenant NameFacility Occupancy TypeElderlyDevelopmentally Disabled AdultsDevelopmentally Disabled ChildrenHospice PatientsFor ARF Facility Services LevelDoes the Facility Admit Residents with Alzheimer’s Disease? Yes No If yes, what percentage%Facility License number:Number of licensed Beds:Does the operator reside on premises? Yes No Is this a New Venture under 3 years? Yes No If yes, # of years business operator has managed assisted living or other care facilities?Property Limits RequestedBuilding Coverage Limit (Replacement Cost of Building)Personal Property Limit (All items to operate business)Deductible Amount$500$1,000$2,500$5,000$10,000$25,000Wind and Hail Deductible ( not Applicable in CA, NV, OR and UT)$50,000$75,000$100,000$250,000StructuresBuilding InformationAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Building Construction TypeFrameMasonryNon-CombustibleOtherYear BuiltAge of RoofRoof ConditionRoof Cover TypeComp ShinglesTar and GravelTileWood Shingle/ShakeMetalOtherYear the Following Were Brought Up To Date:Wiring/Electrical PanelHeatingPlumbingPlumbing TypePEX %Please enter a number less than or equal to 100.Galvanized Pipe %Please enter a number less than or equal to 100.Copper Pipe %Please enter a number less than or equal to 100.Other %Please enter a number less than or equal to 100.Is 100% of Wiring on Circuit Breakers? Yes No Percentage of Total Living Space Above GarageNone25%50%75%100%Fire Sprinkler System Yes No Distance From Approved Hydrant (FT)Distance from Responding Fire Station (Miles)Protection Class#Is Building Bolted to Foundation? Yes No If Basement, Amount of Area That Is FinishedPlease enter a number less than or equal to 100.Exterior Wall MaterialWood/FrameFrame StuccoBrickOtherIs facility furnished? Yes No Number of units furnishedDoes Facility Have Wood Burning Heating Device: Yes No Facility OperationsWhat is the annual rental income?Does the Insured Employ a Property Manager Firm? Yes No If yes, name of FirmDoes the Insured Require a Security/Damage Deposit from Tenants? Yes No If yes, how much?Building Value Computation Information:Square Footage of BuildingSquare Footage of BasementSquare Footage of Other StructuresIf yes, please describeSquare Footage of Porches, Decks, and Unfinished AreasSquare Footage of Attached GarageSquare Footage of Detached GarageOptional CoveragesEarthquake Sprinkler Coverage EQSL? Yes No Equipment Breakdown Coverage? Yes No Increased Building Ordinance Coverage? Yes No Personal Property of Building Owners: STATE COST TO REPLACE WITH PROPERTY OF LIKE KIND, UTILITY AND QUALITYFurniture and Trade FixturesMachinery, Computers, EquiptmentOtherTotalAdditional Underwriting InformationIs Facility in or Near a Wooded Area? Yes No If yes, Distance to AreaIs Facility in or Near a Designated Brush Area? Yes No If yes, Distance to AreaAre There Any Unusual Exposures We Should Know About Yes No Quality Grade of ConstructionEconomyStandardAbove AverageCustomPremiumProperty Slope?None (0-15 deg)Moderate (16-30 deg)Steep (Over 30 deg)Is Facility Near a Body of Water? Yes No Any Docks or Piers on Premises? Yes No Does the Facility Have a Wood Burning Heating Device? Yes No Is there a Pool or Spa? Yes No If yes, is there a Security Fence Surrounding the Pool/Spa? Yes No Are there any Diving Boards? Yes No Please read Carefully This application, including Section II Per location, and any attachment(s) in its entirety will be considered part of the policy. When the declaration and forms are distributed, a copy of the application you have provided will not be included. Please be sure to retain a copy of the application(s) for your file. An unsigned and undated application will not be considered. The signing of this application does not bind the company to offer insurance nor does it bind the signer. Printed NameSignatureTitleDate MM slash DD slash YYYY Untitled* I acknowledge and agree to submit this information
