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Condo/Co-op/Apartment Insurance Application
Condo/Co-op/Apartment Insurance Application
Applicant's Name:
(First)
(Middle)
(Last)
Other Named Insured:
(First)
(Middle)
(Last)
Mailing Address:
(Street Address)
(City)
(State)
(Zip)
Property Address (if different mailing):
(Street Address)
(City)
(State)
(Zip)
Previous Address (if current is less than three years):
(Street Address)
(City)
(State)
(Zip)
Telephone Number: Home
Work
Cell
Fax
Liability Coverage Requested:
25,000/50,000
50,000/100,000
100,000/300,000
250,000/500,000
Email Address:
Social Security #:
Date of Birth:
(mm)
(dd)
(yy)
Marital Status:
Married
Single
Separated
Divorced
Widowed
Applicant Occupation:
Name of Employer:
Address of Employer:
# of years in current occupation:
# of years with current employer:
Smoker
Non-Smoker
Co-Applicant
Name of Co-Applicant:
(First)
(Middle)
(Last)
Other Named Insured:
(First)
(Middle)
(Last)
Mailing Address:
(Street Address)
(City)
(State)
(Zip)
Property Address (if different mailing):
(Street Address)
(City)
(State)
(Zip)
Previous Address (if current is less than three years):
(Street Address)
(City)
(State)
(Zip)
Telephone Number: Home
Work
Cell
Fax
Liability Coverage Requested:
25,000/50,000
50,000/100,000
100,000/300,000
250,000/500,000
Email Address:
Social Security #:
Date of Birth:
(mm)
(dd)
(yy)
Marital Status:
Married
Single
Separated
Divorced
Widowed
Applicant Occupation:
Name of Employer:
Address of Employer:
# of years in current occupation:
# of years with current employer:
Occupancy:
Owner
Tenant
Unoccupied
Vacant
Primary Residence:
Yes
No
Occupied Daily:
Yes
No
Usage Type:
Primary
Secondary
Seasonal
Structure Type:
Apartment
Co-op
Condo
Is there a manager on premises?
Yes
No
Is there a security attendant?
Yes
No
Is the building entrance locked?
Yes
No
Structure:
Brick
Frame
Glass
Steel
Other:
Building Type:
Fire Escape
Fire Resistive
Year Built:
Square Footage:
Number of apartments in building:
Number of Rooms in apartment:
Fireplace:
No
Yes, Amount:
Burglar Alarm:
None
Local
Central
Smoke Detector Alarm:
None
Local
Central
Deadbolt
Fire Extinguisher
Type of heating:
Gas
Oil
Other:
If oil heating, is boiler on premises:
Yes
No
Value of personal property: $
Value of Kitchen: $
Value of Bathroom(s): $
Purchase Date:
(mm)
(dd)
(yy)
Purchase Price: $
Deductible Requested:
$250
$500
$1000
Prior Insurance Information
Prior Insurance Carrier:
Policy #
Requested starting date of new policy:
(mm)
(dd)
(yy)
Do you need additional coverage for any of the following items valued at a minimum of $1000 per item
Fine Arts or Valuables
Jewelry
Collectible (Rare Books, Coins, Stamps etc.)
Do you own a vehicle?
Yes
No
Would you like an Auto Quote?
Yes
No
Year
Make:
Model:
VIN #:
