Landlord Insurance Application Form

Landlord Insurance Application Form

Applicant / Insured Information

Applicant Name:

Date of Birth:    Phone:    Email:

Property to be Insured

Year Built:    Construction Type:    Number of Units:

Occupancy Type:    Annual Rental Income:

Policy Details Requested

Effective Date:    Expiration Date:

Coverage Options (select all that apply)

  Property / Building Coverage
  Contents Coverage (owner provided items)
  General Liability Coverage
  Loss of Rent / Rental Income
  Vandalism & Malicious Mischief
  Theft of Owner Property
  Equipment Breakdown (boiler/AC)
  Earthquake (Optional; additional premium applies)
  Flood (Optional; subject to eligibility)

Liability Limits

Property Protection & Security

Smoke / CO Detectors Installed: Yes No    Burglar Alarm: Yes No

Fire Sprinkler System: Yes No    On-site Management: Yes No

Loss History & Prior Insurance

Has any property to be insured suffered a loss (fire, water, flood, earthquake, crime) in the past 5 years?    Yes No

Mortgagee / Loss Payee / Beneficiary Information

Exclusions, Conditions, and Declarations

The applicant understands and acknowledges that coverage is subject to policy terms, conditions, limits and exclusions. Typical exclusions include but are not limited to loss caused by wear and tear, neglect, intentional acts, war, nuclear hazard, dishonest acts by tenants not covered unless specified, and loss by flood or earthquake unless specifically endorsed. Selection of optional coverages (earthquake, flood) requires separate underwriting and additional premium.

By signing below the applicant certifies that all information provided is true, accurate and complete to the best of the applicant's knowledge. The applicant understands that any material misrepresentation, omission or concealment may result in denial of coverage or rescission of the policy. The applicant authorizes inspection of the described property and verification of any statements contained herein, including loss history and prior insurance information.

Applicant Certification

I declare under penalty of perjury that the statements made in this application are true and complete. I understand that this application becomes part of any policy issued, and that coverage will be effective only if a policy is issued and the first premium is paid. I consent to the insurer's use of my information for underwriting, claims and policy administration purposes and to communicate with me by the contact methods provided above.

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