Fillable VACANT LAND APPLICATION FORM (Abram Interstate Insurance)

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VACANT LAND APPLICATION FORM (Abram Interstate Insurance)

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ATR – 103 Vacant Land Application
Page 1 of 2
VACANT LAND 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.
ELIGIBILITY QUESTIONS
1. In which state is the property to be insured:
2. Has the applicant had any claims or losses in last 3 years at the land to be insured?
3. Has the applicant had any policy of liability insurance refused, cancelled
or non-renewed in the past 3 (three) years?
4. Has/Is the applicant currently involved in bankruptcy proceedings?
Yes No
5. Is the land to be insured subject to more than two mortgages or other encumbrances?
6. Does the land to be insured exceed 500 acres?
7. Is the land to be insured located in a landslide, forest fire or bush fire area?
8. Is the land to be insured leased to others?
Yes No
9. Has the land to be insured ever been used as a dump site, landfill or are there any
other potential environment exposures or hazards?
10. Are there any of the following on the land to be insured? Abandoned equipment,
blasting exposures, caves, oil or gas wells, mines below the ground that are not sealed,
quarries, railroad operations, or underground fuel storage.
11. Are there any activities taking place on the land to be insured? Including but not limited
to ATVs, dirtbikes,snowmobiles, mountain biking, bmx, skateboarding, long boarding, rock
climbing, swimming, hunting, fishing, logging, forestry work.
Yes No
12. Any water hazards on the land to be insured? Including but not limited to lakes,
rivers and reservoirs.
1
3. Does water exceed an area greater than an acre? Yes
No
14
. Are there any Levees, Dams, Reservoirs on land to be insured?
15. Are ‘No Swimming Allowed’ signs clearly visible around any lake or body of water?
16. Are ‘No Trespass’ signs clearly visible at all entries to the vacant land to be insured?
Yes No
ATR – 103 Vacant Land Application
Page 2 of 2
APPLICANT DETAILS
Name and Mailing Address of Applicant:
State
Zip code
17. Applicant Type: Individual Partnership Joint Venture Corporation LLC Other
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
18. Size of Land in acres? 1-11-25 26-5051-10001-20001-30001-40001-500
19. What was the prior use of the land?
20. What future plans for use of the land?
21. Is the property fenced/posted?<es No
22. Premises Liability: $100,000/$200,000300,000/$600,000500,000/$1,000,0001,000,000/$2,000,000
23. Medical Payments: $1,0002,5005,000 $10,000
24. Is TRIPRA coverage required?<es No
25. Have there been any insured or uninsured losses or claims at the location to be insured? Yes1o
Describe all prior losses or claims including the date, the nature or occurrence, the status, the amount, and whether the damage has been
repaired:
26. Identify all mortgagees, lien holders and additional loss payees (if any, including account numbers and outstanding amounts):
27. 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 DE
NIED.
Applicant’s Signature
Retail Broker’s Signature
Date
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VACANT LAND APPLICATION FORM (Abram Interstate Insurance)

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Completed 10 July 2021

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