Insurance New Business Renters Form

INSURANCE NEW BUSINESS RENTERS APPLICATION

Applicant Name:   Date of Birth:

Applicant Contact & Residency

Phone:   Email:

Policy & Premises Information

Proposed Effective Date:   Policy Term (months):

Apartment    Condominium    House    Other

Owner-Occupied:    Tenant-Occupied:    Seasonal/Short-term Rental:

Coverage Selections

Select coverages to be quoted and proposed limits:

Include personal property    Limit: $

Include loss of use    Limit: $

Include personal liability    Limit: $

Include medical payments    Limit: $

Underwriting & Risk Information

Has the applicant had any property or liability claims in the past five years? Check if yes:

Is the applicant currently aware of any circumstance that could give rise to a claim? Check if yes:

Any history of eviction, bankruptcy, or criminal conviction related to the premises? Check if yes:

Additional Property Information

Smoke detectors    Deadbolt locks    Alarm system    None reported

Yes    No    If yes, list breed/type and number:

Beneficiary Designation

Designated beneficiary for policy proceeds (if applicable). Payment of certain benefits may be made to a beneficiary as provided by policy terms.

Exclusions & Notices

The policy applied for will contain exclusions, limitations and conditions. Typical exclusions include but are not limited to loss arising from war, nuclear hazard, intentional acts, wear and tear, and damage from flooding unless specifically endorsed. Coverage for business property, high-value items, and certain dog breeds may be restricted or require specific endorsement.

The insurer reserves the right to decline or modify coverage based on underwriting review. Quotes provided are subject to verification of information here and to completion of any required inspection, documentation, or additional disclosures.

Declaration & Authorization

I certify that the information provided in this application is true, correct and complete to the best of my knowledge. I understand that any material misrepresentation, omission or concealment of fact may result in denial of coverage, cancellation of the policy or rescission pursuant to policy terms and applicable law.

I authorize the insurer and its representatives to obtain information necessary to process this application, including but not limited to prior claim history, credit information where permitted by law, criminal history as it relates to insurability, and loss history. I further authorize representatives to inspect the property described in this application prior to or after issuance of a policy.

Fraud Warning: Any person who knowingly presents false information in an application for insurance or submits false claims may be guilty of insurance fraud under applicable law and may be subject to civil and criminal penalties.

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