ATR – 17 Dwelling Application Page 2 of 2
COVERAGE AND PROPERTY DETAILS
15. Protection Class: 16. Period of Insurance: 3 Months 6 Months 9 Months Annual
1. Total Sq Footage of building to be insured including outbuildings:
1. Is Vacant Condominium Unit Owners Coverage required? Yes No
1. Value of Building: (Total value of Main Building excluding Other Structure(s)): _______
. Construction Type? )UDPH -RLVWHG0DVRQU\1RQ&RPEXVWLEOH Masonry 1on &ombustible0RGLILHG)LUH5HVLVWLYH)LUH5HVLVWLYH
2. Age of Building or complete building upgrade in? (This includes plumbing, electric, roof) 0-30 Years 31-50 Years Over 50 Years
2. Are there any other Structures to be insured? Yes No 2. Value of Other Structure(s):
2. Please provide a brief description:
2. Do you require personal property? Yes No
2. Value of personal property to be insured: ______________
2. Wind and Hail Deductible per occurrence: $500 $1,000 $2,500 $5,000 $7,500 $10,000 $25,000
2. All Other Perils Deductible (excluding Wind Peril): $500 $1,000 $2,500 $5,000 $7,500 $10,000 $25,000
2. Type of Quote: DP-1 DP-3
. Estimated Renovation or Construction Work Project Costs:
3. Description of Renovation or Construction Work:
3. Is Work being undertaken by a Contractor? Yes No
3. What CGL Limit carried by the Contractor? 300k 500k 1m
3. I
s Vandalism and Malicious Mischief cover required? Yes No
3. Premises
Liability: Yes No
3. Pr
emises Liability limits: $25,000 $50,000 $100,000 $300,000
$500,000 $1,000,000
3. How often is the building to be insured inspected by the applicant or the applicant’s representative? Daily Weekly Monthly Other
3. Which Utilities are operational: Electricity only Water only Electricity & Water None
3. Is there a fully functional Central Station Burglar Alarm with active monitoring contact? Yes No
. 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:
4. Identify all mortgagees, lien holders and additional loss payees (if any, including account numbers and outstanding amounts):
4. If required, please enter below details of Additional Insured:
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
