Coastal Master Condo Application
Agency: ________________________ Contact Person: ________________________ Phone: _______________
Email: ____________________ Effective Date: _________ Insured: ____________________
Location Address: ___________________________
Owner Secondary Short Term Rental Annual Rental
Bankruptcy/Foreclosure/Repossession within past three years? Yes No
Losses in Past Three Years
Date of Loss: ______________ Details of Loss: ____________________________________________________
Amount Paid: __________________ Open/Closed: ____________________________
Protection Class: ____________ Construction Type: __________________ Number of Units: _________________
Property Deductibles: $500 $1,000 $2,500 $5,000
Plumbing Type: ____________ Roof Type: ____________ Wiring Type:____________ Heating Type: ____________
Year Built: ___________ Year Updated: Plumbing _______ Roof: _______ Wiring: ________ Heating: ________
Square Feet: _____________
Check all that apply:
Lapse >12 months Business on premises Arson or fraud Home daycare
Woodstove/kerosene heater Asbestos/EIFS Aluminum/Knob & Tube
Coverage Limits:
Dwelling:________ Other Structures: ________ Liability:________ Med Pay: _________
Water Backup: $5,000 $10,000 Extended. Repl. Cost: Yes No Ordinance of Law: Yes No
Central fire/burglar alarms: Yes No Gated Community: Yes No Sprinkler System: Yes No
Swimming Pool or Hot Tub: Yes No
Target Premium: _________________________
Some coverage options, deductibles or limits requested above may not be available for certain markets of insurance.
Terms will be offered based on eligibility of the risk and coverage availability, and are always subject to underwriter
review of a full application.
1-800-368-2095 | www.simple-rates.com
| plines@aslinc.com
