Fillable VACANT COMMERCIAL APPLICATION FORM (RT Specialty)

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VACANT COMMERCIAL APPLICATION FORM (RT Specialty)

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VACANT COMMERCIAL APPLICATION FORM
THE ANSWERS TO THESE QUESTIONS FORM PART OF AN APPLICATION FOR INSURANCE ONLY. NOTHING IN THIS APPLICATION
SHALL BE DEEMED AN AGREEMENT TO PROVIDE INSURANCE AND UNDERWRITERS MAY DECLINE TO OFFER COVERAGE OR
OFFER COVERAGE ON TERMS THAT DIFFER FROM THE COVERAGE SOUGHT BY THE APPLICANT.
GENERAL DETAILS
Name and Mailing Address of Applicant:
State Zip code
Telephone
Email
Address of Property to be Insured:
State Zip code
Name and Address of Retail Broker:
State Zip code
CONTACT DETAILS
Contact Name
Telephone
Email
COVERAGE AND PROPERTY DETAILS
1. What type of Cover would you like? Property Package
2. Period of Insurance required: Three months Six months Nine months Annual
3. Total Value of building(s) to be insured:
4. Premises Liability limits: $100,000/200,000 $300,000/600,000 $500,000/1,000,000 $1,000,000/2,000,000
5. Requested Effective Date:
6. Construction Type: Fire Resistive Frame Masonry non combustible Other
7. Protection Class:
8. Total Sq Footage of building to be insured including outbuildings:
9. Age of Building or complete building upgrade in?
(This includes plumbing, electric, roof) 0-25 Years 26-50 Years Over 50 Years
10. Number of Floors of Main Building to be insured: ___ 11. Is Vandalism cover required? Yes No
12. Is Sprinkler Leakage cover required? Yes No
13. Are there any other Structures to be insured? Yes No 14. Value of Other Structure(s):
Please provide a brief description:
15. All Other Perils Deductible (excluding Wind Peril): $500 $1,000 $2,500 $5,000 $7,500 $10,000 $25,000
16. Wind and Hail Deductible per occurrence: $500 $1,000 $2,500 $5,000 $7,500 $10,000 $25,000
17. How often is the building to be insured inspected by the applicant or the applicant’s representative? Daily Weekly Monthly Other
18. Which Utilities are operational Electricity only Water only Electricity & Water None
19. Is there a fully functional Central Station Burglar Alarm with active monitoring contact? Yes No
20. Prior use of building to be insured when last occupied?
21. Have there been any insured or uninsured losses or claims at the property to be insured? Yes No
Describe all prior losses or claims including the date, the nature or occurrence, the status, the amount, and whether the damage has been
repaired:
ATR – 15 Commercial Application Page 1 of 2
Submit Application
COVERAGE AND PROPERTY DETAILS (continued)
22. Identify all mortgagees, lien holders and additional loss payees (if any, including account numbers and outstanding amounts):
23. If required, please enter below details of Additional Insured:
24. Is there a parking lot at the property to be insured? Yes No 25. If yes, is it fenced and posted? Yes No
ELIGIBILITY QUESTIONS
26. In which State is the property to be insured:
27. Please confirm the type of property to be insured: Residential Commercial Farm Other
28. Please enter the period the property has been vacant: 0-6 months 7-13 months 14+ months
29. Has the property to be insured been continuously covered by a policy of property insurance since becoming vacant? Yes No
30. Is the building(s) to be insured secured against unauthorized entry? Yes No
31. Has the applicant had any policy of property insurance cancelled or non-renewed in the past
3 (three) years for reasons other than vacancy? (Not applicable to risks located in MO. For MO
risks please select 'No'.):
32. Is the applicant currently involved in bankruptcy proceedings?
33. Is the property to be insured subject to mortgage foreclosure proceedings or tax liens?
34. Has the property to be insured been condemned or is it scheduled for demolition?
35. Existing damage to building(s) to be insured?
36. Is the property to be insured subject to more than two mortgages or other encumbrances?
37. Has the applicant been convicted of the crimes of arson or insurance fraud?
Yes No
38. Is the property to be insured undergoing any renovation or construction work of any kind, or is any such work due to commence while
insurance is in effect? Yes No
If the answer above is “yes” please answer the following question
39. Is the renovation or construction work (i) being performed by a contractor or owner where project costs exceed $250,000; or (ii) involve
structural work or structural repairs being performed by any person? Yes No
SUPPLEMENTARY RENOVATION QUESTIONS (WHERE APPLICABLE)
40. Estimated Renovation or Construction Work Project Costs:
41. Description of Renovation or Construction Work:
42. Is Work being undertaken by a Contractor? Yes No
43. What CGL Limit carried by the Contractor? 300k 500k 1m
DECLARATION
THE ANSWERS GIVEN IN THIS APPLICATION ARE CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT
THESE ANSWERS WILL FORM PART OF A POLICY THAT IS SUBSEQUENTLY OFFERED. I ALSO UNDERSTAND THAT
ANY FALSE STATEMENT MAY VOID THE INSURANCE IN ITS ENTIRETY OR RESULT IN A CLAIM BEING DENIED.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR
THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A
FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND (NY:
SUBSTANTIAL) CIVIL PENALTIES. (NOT APPLICABLE IN CO, HI, NE, OH, OK, OR, VT FOR WHICH SEE ATTACHED). IN
DC, LA, ME, TN AND VA, INSURANCE BENEFITS MAY ALSO BE DENIED.
Applicant’s Signature
Retail Broker’s Signature
Date
Date
ATR – 15 Commercial Application Page 2 of 2
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VACANT COMMERCIAL APPLICATION FORM (RT Specialty)

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Completed 31 July 2020

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