Fillable SURPLUS LINES YURT APPLICATION (Risk Placement Services, Inc.)

Fill Online, Printable, Fillable, Blank SURPLUS LINES YURT APPLICATION (Risk Placement Services, Inc.) Form

Use Fill to complete blank online RISK PLACEMENT SERVICES, INC. pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

SURPLUS LINES YURT APPLICATION (Risk Placement Services, Inc.)

On average this form takes 29 minutes to complete

The SURPLUS LINES YURT APPLICATION (Risk Placement Services, Inc.) form is 2 pages long and contains:

  • 2 signatures
  • 25 check-boxes
  • 97 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Risk Placement Services, Inc. forms online.

BROWSE RISK PLACEMENT SERVICES, INC. FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Yurt (01-15)
Coverage: Fire, Extended Coverage and
Vandalism & MM* (VMM. Excludes damage
caused by the Owner, Owners family, Tenant,
Guest, any animal or vermin)
Agent Code:____________
SURPLUS LINES YURT APPLICATION
Desired Effective Date: __________________________ **Check Term: (3) Month (6) Month Term (12) Month Term
Name of Applicant: _________________
____________________________________Phone No. ___________________
Indicate legal owner of risk if not the same as Applicant:
Applicants Mailing Address: __________________________________________________________________________
Number, Street, City, State, Zip, County
Location of Yurt to be insured:_________________________________________________________________________
(If different than mailing address)
Bill Mortgagee Bill Insured
(down payment must accompany app.)
Mortgagee/Lienholder Contract Seller Additional Interest Loan Number(s):_________________________
#1) Name:________________________________________________________________________________
Address:_______________________________________________________________________
#2) Name:_________________________________________________________________________________
Address:________________________________________________________________________
Year manufactured: _________ Square footage:________ Square footage of the living area only:_________
Did the proposed insured purchase this yurt new?________ How many doors does the yurt have?______
Windows?___________
Did the proposed insured construct the yurt at the above location themselves?___ Does the yurt have a snow kit attached?___
Does the yurt have a wind kit attached?______ Does the yurt have an insulation package?______ Any other information about this
yurt?_______________________________________________________________________________________________________
Does the yurt conform to all local planning regulation and building codes? Yes No, if No, Explain:______________
Protection Class: __ # of acres?____ Foundation: Slab
(continuous concrete) Crawlspace Basement –( )% Finished
Feet to fire hydrant_________ Miles to nearest fire department_____________ Is this a volunteer fire department?_____
Primary heating method_____________________________Fuel________________________________________
Electrical: fuses circuit breakers Other ____________________________
Supplemental Heat: Woodstove: Yes No If yes, is this the primary source of heat? Yes No -Type of chimney:__
If Yes, indicate type of supplemental heat: woodstove pellet stove fireplace insert
Is Yurt continuously occupied? Yes No Is Yurt currently occupied? Yes No
Is Yurt occupied by Owner/Primary Owner/Seasonal* Renter Renter/Seasonal* Vacant**
*If Seasonal, will the Yurt be occupied for living purposes at least one (1) full day out of each 45 day period? Yes No
*If Seasonal, will the Yurt be rented? Yes
No
**Why is the yurt Vacant?
**If Vacant. The EARLIEST DATE on which the property became vacant was__________________________________
Check Deductible desired: $500 $1,000 $2,500 (Higher deductibles may be applied with no credit at the Underwriters discretion.)
AMOUNT PREMIUM
$ On Yurt $
$ On Adjacent Structures/Outbuildings
$ On Contents/Personal Property
$ On Liability $
$ On Burglary $
Subtotal (Minimum Premium $500.00)** $
Policy Fee (Does not apply to MT) $ 50.00
State Taxes $
Fire Marshall Fee $
SLSC Tax $
Total $
Amount remitted) $
Yurt (01-15)
Occupation of Applicant: __________________________________ Employer: __________________________________
Spouse: ______________________________________________ Employer: __________________________________
Have you been convicted of a crime in the last 7 years? ____Yes _____No If yes, please explain___________________
_________________________________________________________________________________________________
*Any business on premises? Yes No if yes, explain _____________________________________________________
*Please note: Any outbuilding used in whole or part for commercial manufacturing or farming business is
not covered.
Does applicant own any animal(s)? Yes No This policy does not provide liability coverage for any type of animal.
Prior insurance carrier: _________________ Policy No.: _______________- if none, please explain _________________
_________________________________________________________________________________________________
Has insurance been canceled, non-renewed or refused in the past three years? Yes No If yes, explain ____________
_________________________________________________________________________________________________
Has risk sustained any losses in past 5 years? Yes No If yes, provide location, cause, date and amount of loss: _____
Coverage will become effective, if accepted, upon written notice by RPS-MIS and coverage will not commence earlier than the date
received in the office of RPS-MIS.
Applicant/Producer Statement: I hereby state I have been unable to produce the above requested coverage from standard insurers. I
request RPS-MIS to effect coverage and I will be responsible for payment of premium, fees and taxes. I understand coverage will not
be effective until accepted by RPS-MIS and flat cancellations are not permitted. I warrant all above answers to be true and
understand coverage, if accepted, will become void at any time the covered property has been *vacant or unoccupied for
more than 30 days:
______________________________________________ _________________________________________________
Applicant’s Signature Date Producer’s Signature Date
*Thirty (30) day vacancy clause does not apply to risks written in the Vacant or Seasonal/Secondary Programs.
PLEASE NOTE: Three month vacant policies have a fully earned premium. Six month vacant policies have a
50% minimum earned premium.
Producer Code: ___________ Producer’s E-mail Address: _______________________________________
Producer ________________________________________________________________________________________
Address _________________________________________________________________________________________
Phone No _____________________________________________ Fax No ____________________________________
AGENTS: A completed Surplus Lines Statement (Due Diligence) must accompany the application if required for
your State.
PHOTO REQUIREMENTS
Photos are required on all risks submitted and must include 2 photos of the exterior of the yurt, one of the
inside, including the front door area and any windows if applicable.
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

SURPLUS LINES YURT APPLICATION (Risk Placement Services, Inc.)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 30 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document