Insurance Rental Questionnaire

INSURANCE RENTAL QUESTIONNAIRE

Applicant / Insured Information

Insured Name:

Contact Phone:    Email:

Date of Birth (if individual):    Entity Type: Individual Corporation LLC Partnership

Property Information

Property Address:

Year Built:    Construction Type:    Number of Stories:

Total Units Rented:    Average Monthly Rent Per Unit: $    Primary Tenant Type:

Rental Operations & Maintenance

On-site Manager or Agent:    Contact Phone:

Do you require credit/background checks? Yes No    Eviction Proceedings in last 5 years: Yes No

Security & Fire Protection

Smoke Detectors: Installed and Maintained Not Installed    Fire Alarm / Sprinkler System: Yes No

Loss History & Prior Insurance

Have there been any claims or losses in the past 5 years? Yes No

Has any policy been cancelled or non-renewed in the past 3 years? Yes No

Policy & Coverage Requested

Policy Type Requested:

Property Damage    Liability    Loss of Rental Income    Earthquake    Flood    Equipment Breakdown

Requested Coverage Limit: $    Deductible: $    Estimated Annual Premium: $

Policy Period From: To:

Exclusions & Special Conditions

The insurer may apply exclusionary endorsements, higher deductibles, or special conditions where risk factors exist. Notable risk factors include vacancy greater than 30 days, unmanaged subletting, inadequate fire protection, known structural defects, or repeated prior losses. Applicant must disclose all material facts affecting risk.

Beneficiary / Loss Payee

Beneficiary / Mortgagee Name:

Relationship to Insured:    Payment Percentage: %

Declaration & Certification

I declare that the statements made in this questionnaire are true and complete to the best of my knowledge. I understand that this questionnaire is part of the application for insurance and that any material misrepresentation or omission may result in denial of coverage, cancellation of the policy, or rescission of coverage. I authorize the insurer to obtain loss history and underwriting information relevant to this application. I acknowledge that completion of this form does not bind the insurer to issue a policy nor bind the applicant to accept coverage.

The applicant agrees to promptly notify the insurer in writing of any change in occupancy, security, or condition that materially increases the risk of loss. The applicant further agrees to maintain accurate records of tenants and to permit inspection of the premises by the insurer or its representative upon reasonable notice.

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