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RSA Insurance Web 072120

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As a New York City apartment building owner, you
understand the importance of protecting your investment
and you need the most cost-effective insurance coverage
options available to help you minimize your risk. At
RSA Insurance Agency, we know that the unexpected
sometimes happens in life and so, we work tirelessly to
provide our clients with a standard of care and service
that translates to peace of mind.
Our goal at RSA Insurance Agency is to offer you the
best and broadest coverage, tailor-made for you, at the
most competitive price, while providing you with Respect,
Service and Accountability you can rely upon.
Let RSA Insurance Agency get to work for you. Our team
will begin with a comprehensive review of your current
policy, at no cost to you. With access to hundreds of
top-rated insurance carriers, we will then search for
alternatives that will save you money, while offering you
the proper coverage required from an insurance carrier
which will be there for you when you need them.
At RSA Insurance Agency, our priority is you. Our team of
dedicated insurance professionals is available to answer
questions, explain coverages, and assist with all of your
insurance needs. We look forward to working with you
Contact us today to get started!
123 William Street, 12
th
Floor, New York, NY 10038
TEL: 212-214-9248 or 212-214-9351
•
FAX: 212-732-0708
E-MAIL: insurance@rsanyc.org
INSURANCE APPLICATION
To be completed for each building
(If you own more than 5 buildings, please call for a spreadsheet)
RSA Member Number
Owner’s Name
Effective Date of Insurance
Named Insured (Should match the legal name on property deed)
Mailing Address City/State Zip Code
Cell #
Business or Home #
E-mail Address
Fax #:
CONTACT INFORMATION
Contact Name for Inspection
Title/Relationship to Owner
Contact #:
Contact Email:
Insured Location/ Building Address City/State Zip Code
Select type of building: Apartment House Apartment with restaurant exposure Apartment with commercial space SRO (Single Room Occupancy)
Select type of construction (the exterior of your building): Wood Frame Masonry Fire Resistive
Building Insurable Value/ Replacement Cost Value (Total Sq. Ft. of Bldg. X $200 - $300):
$
Year Built
Year Renovated
Annual Rental Income (Monthly Rents X 12): $
Personal Property (Owner Occupied Only): $
Property Deductible: (Select One):
$1,000 $2,500 $5,000 $10,000
Number of Years Bldg. Owned?
# of Floors:
If more than two floors, are there fire escapes or another
means of egress above the second floor? Yes No
#
of Units:
Residential Sq. Ft. (L x W x # of floors):
Occupancy rate (%):
# of Comm. Units:
Comm. Occupancy (Type of Business)
Comm. Sq. Ft.
Certificates on file: Yes No
Type of management for this building: Live-in-super Owner occupied Management Company (24 hour service) None/ Self-Managed
Please provide year in which each of the following were updated (if done over time indicate most recent year):
Roof __________ Electrical Wiring ___________ Boiler ____________ Plumbing __________
Does the property meet all the current state and local life safety codes? Yes No
Is there a Restaurant on premises? Yes No
Are cooking surfaces ANSUL
protected? Yes No
Is liquor served? Yes No
Does building have an elevator? Yes No
If so, are inspection certificates on
file? Yes No
# of Elevators
Do all units have smoke/carbon monoxide detectors? Yes No
Battery or Hardwire
Do all common areas have sprinkler
systems?
Yes No
Illuminated EXIT signs? Yes No
Children in occupancy: Yes No; If so, #:
Do windows have windows guards?
(as required): Yes No
Is Lead-Based Paint cvg required?
Yes No
Is there a swimming pool?
Yes No
Dogs/Cats? Yes No
If so, #: _______
Breed(s)?
How are the housekeeping and building conditions? Average Above Average Below Average
Current insurance carrier/ company?
Current insurance premium?
Name of mortgage company
Address of mortgage company City/State Zip Code
Signature
Date
The following will also be required in order to provide accurate quoting:
3-5 years of Loss History Reports/ Loss Runs/ Loss Experience is required by all insurance carriers
Please request this report from your current or former broker, as this documentation is required regardless of your claim history.
A copy of the Declarations Pages of your current policy
123 William Street, 12
th
Floor
New York, NY 10038
TEL: (212) 214-9248
TEL: (212) 214-9351
FAX: 212-732-0708
EMAIL: insurance@rsanyc.org
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RSA Insurance Web 072120

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Completed 30 May 2021

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