Insurance Vacant Binder

INSURANCE VACANT BINDER

Binder Identification

Binder Number:    Effective Date:    Expiration Date:

Insured / Applicant Information

Date of Birth of Primary Named Insured:    Contact Phone:    Email:

Property and Vacancy Details

Property Type: Residential Commercial Multi-family Vacant land

Date Property Became Vacant:    Anticipated Re-occupancy Date:

Policy and Coverage Details

Policy Type:    Coverage Period: From To

Building (Limit: $ )
Contents (Limit: $ )
Liability (Limit: $ )
Vandalism & Malicious Mischief
Fire / Lightning
Water Damage (limited)
Theft (limited)

Deductible: $    Binder Premium Due: $    Payment Terms:

Exclusions and Limitations

The coverage provided by this binder is subject to the insurer's form language, endorsements and exclusions that will be set forth in the final policy. Notwithstanding any selection above, this binder does not provide coverage for:

1. Loss caused by wear and tear, gradual deterioration, corrosion, rust, vermin, rot or inherent vice.
2. Loss arising from illegal activity, deliberate acts by the insured, or unlawful occupancy.
3. Loss from flood, earthquake, war, nuclear hazard, or governmental action except to the extent coverage is expressly provided by endorsement.
4. Loss to property excluded by endorsement including ordinance or law unless specifically endorsed.

Mortgagee / Loss Payee / Beneficiary

Relationship to Insured:    Insurable Interest Percentage:

Prior Losses & Underwriting Representations

Yes No

Conditions Applicable to Binder

This Binder constitutes a temporary agreement to provide the coverage indicated above, subject to full underwriting, inspection, receipt of required documentation, payment of premium and execution of the insurer's formal policy. Coverage under this Binder shall not extend beyond the Binder Expiration Date unless renewed or replaced in writing by the insurer. Coverage is conditioned upon the accuracy and completeness of all statements and materials submitted to the insurer; misrepresentation or omission of material facts shall void this Binder ab initio.

The insurer reserves the right to amend, modify or withdraw the Binder prior to issuance of a formal policy. Acceptance of premium does not waive the insurer's right to decline coverage based on underwriting. The insured agrees to permit inspections of the subject property and to undertake reasonable vacancy protections as a condition of coverage.

Claims Reporting (If Loss During Binder Period)

Declaration and Applicant Certification

By signing below, the Applicant certifies that the information contained in this Binder application and all attachments is true, complete and accurate to the best of the Applicant's knowledge. The Applicant understands and agrees that any material misrepresentation or omission may render this Binder void and may be grounds for denial of coverage or rescission of any policy issued. The Applicant authorizes the insurer and its representatives to make any inquiries necessary to confirm the information provided herein.

The Applicant acknowledges that this Binder is temporary and shall not confer any rights greater than those expressly set forth in this document. Final coverage, terms, limitations, conditions and endorsements will be established only by the formal policy issued by the insurer.

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