Insurance Vacant Dwelling Application

INSURANCE VACANT DWELLING APPLICATION

Applicant Name:   Phone:

INSURED PROPERTY

Year Built:   Construction: Frame Masonry Other

Number of Units:   Occupancy Type Prior to Vacancy:

Vacant Since:   Anticipated Re-occupancy Date:

Alarm system active Boarded windows/doors Regular inspections arranged Fenced/perimeter secured None

Utilities Status: Electric On Gas On Water On All Shut Off

POLICY & COVERAGE REQUESTED

Policy Period From: To:

Vandalism & Malicious Mischief
Theft (limited during vacancy)
Water Damage (limited)
Ordinance or Law Coverage
Debris Removal / Demolition Costs
Fire Department Service Charge

EXCLUSIONS & CONDITIONS

The requested coverage is subject to underwriting approval. Coverage, if issued, will be expressly limited by policy terms, conditions, endorsements and exclusions. The following matters are illustrative exclusions or conditions commonly applied to vacant dwelling policies and are affirmed by Applicant for underwriting consideration:

1. Loss or damage caused by gradual deterioration, latent defect, wear and tear, rust, corrosion, mold or vermin is excluded. Applicant acknowledges that the insurer will not cover maintenance-related losses arising during vacancy.

2. Loss due to vandalism, theft or malicious acts may be excluded or limited unless security measures specified in this application are maintained and verified. Boarding of openings and an active alarm system may be conditions precedent to payment for certain loss types.

3. Water damage resulting from lack of heat, freezing pipes, seepage or ground water is excluded unless specific endorsement is issued. Applicant must notify insurer prior to any known condition that materially increases risk.

4. Intentional acts, conversion, or fraudulent acts by the named insured or occupants are excluded. Pre-existing damage or loss which occurred prior to the effective policy date is not covered.

LOSS HISTORY & PRIOR COVERAGE

In the past five (5) years, has the property had any insurance claims or losses? Yes No

MORTGAGEE / ADDITIONAL INTEREST

BENEFICIARY / PAYABLE INTEREST

(List persons or entities entitled to proceeds, if applicable)

Relationship:   Percentage:

Relationship:   Percentage:

DECLARATION & AUTHORIZATION

By signing below, Applicant certifies that the statements and answers contained in this application are complete, true and correct to the best of Applicant's knowledge. Applicant understands that any material misrepresentation, omission, or concealment of fact in this application or in any subsequent statement may be relied upon by the insurer to void coverage or deny a claim.

Applicant authorizes the insurer, its agents and representatives to inspect the insured property and to obtain records and information necessary for underwriting and claims handling. Applicant agrees to notify the insurer within thirty (30) days of any change in occupancy or security conditions that would affect the risk.

Applicant acknowledges that submission of this application does not bind coverage. Coverage becomes effective only upon issuance of a policy by the insurer and payment of any required premium. Applicant further acknowledges receipt of any applicable fraud warning and understands that knowingly submitting false information may subject Applicant to civil or criminal penalties.

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