Add Request

Please complete the below information in order to submit this location to your representative.

Who is submitting this form? *

First Name

Last Name

Account ID*

Client's Email*

Desired Effective Date*

Would you like a proposal before adding coverage?*

Yes No

Property Address to be Insured*

Address Line 1

Address Line 2

City

State

ZIP Code

Desired Deductible*

$2,500 $5,000 $10,000+ Need Help Deciding

What deductible would you like?

Once coverage begins, the Occupancy Status will be:*

Rental dwelling - Occupied (including condos) Renovation - Currently undergoing rehab (or within 30 days after acquisition) New Construction Vacant - Not undergoing renovation Force Placed - Vacant Force Placed - Occupied

What is your intent for the property over the next 60 days? *

On the market for sale Renovate and/or occupy No immediate plans

Property Type*

Will there be any structural renovations?*

Yes No

Moving of load-bearing walls or adding square footage to property

Square Footage*

If unknown enter closest approximation

Year Built*

If unknown enter closest approximation

What is the existing building value?* $

What is your expected renovation cost?* $

Coverage Amount Requested (Please Enter "0" for Liability Only)* $

Replacement Cost (RC) and Actual Cash Value (ACV) are coverage options that differ in how a covered loss settlement will be calculated. RC settles claims with the ability to recoup depreciation, whereas ACV does not. Though ACV may be less expensive than RC due to lower insured values, remember, that settlement is subject to non-recoverable DEPRECIATION. With most of our Program policies, ACV is garnered by insuring the location to at least $75 per square foot and RC is garnered by insuring the location to at least $120 per square foot. Some carriers require higher minimums. Please contact us to discuss your coverage specifics.

Loss of Rents Amount Requested* $

If this coverage is desired, enter the monthly rent amount. If not applicable enter, "0".

How many months of Loss of Rents do you want included in your policy?

(i.e. minimum of 6, maximum of 12)

Construction Type*

Block Brick Frame Metal Modular/Mobile

Will this location be used as a Vacation Rental?*

Yes No

Are any recreational activities offered as part of this rental?*

Yes No

Is this location associated with a resort/hotel? *

Yes No

How much coverage would you like for contents?*

i.e., furnishings such as curtains, furniture, stereo, tv, computer equipment, etc

Is this location leased to students? *

Yes No

Is this on or off campus student housing?*

On Off

Are you renting to undergrad or graduate students?*

Undergrad Graduate

Are there separate leases per room or one lease per building?*

Separate Leases One Lease

Are parents required to cosign on the lease?*

Yes No

Do you require renters insurance from each tenant and obtain COIs with the owning entity listed as an additional insured?*

Yes No

Number of Units*

Are all of these units in one building?*

Separate occupied buildings must be insured as separate locations in our program

Is this location part of a complex with more than 20 residential units?*

Yes No

Is this location part of a complex with more than 20 residential units?*

Yes No

Does the client own all units in the complex?

Yes No

Is there a pool, spa, or hot tub at this location? (Including HOA or Condo Complex Pools).*

Yes No

Does the pool, spa, or hot tub meet current municipal code, have self-closing/self-locking gates or doors, and abide by the Virginia Graeme Baker Pool and Safety Act?*

Yes No

Does the pool, hot tub, and/or spa have a diving board or slide?*

Yes No

Does the association maintain the pool, spa, or hot tub?*

Yes No

Does the association maintain the pool, spa, or hot tub?*

Yes No

UPDATES

Please provide approximate year of last update. If unknown the year built will be used.

Roof*

Electric*

Plumbing*

HVAC*

Are there any existing city/state housing code violations associated with this property?*

Yes No

Please Explain:*

Are there any local/state rental law, code or statute violations associated with this property? *

Yes No

Please Explain: *

Are locks changed or replaced upon a tenant leaving?*

Yes No

Are there any existing damage or maintenance issues at this property?*

Yes No

Non-cosmetic issues that affect livability

Please Explain: *

Does the location have a wood shake roof?*

Yes No

When required, are the heating, electrical and plumbing systems serviced by a qualified trade professional?*

Yes No

Is (either) Knob-and-Tube or Aluminum Wiring present?*

No Yes, Aluminum Yes, Knob-and-Tube Unknown

All wiring used by the property, including service lines. If unknown, coverage may be diminished.

Has the Aluminum Wiring been remediated?*

Yes No

All forms of remediation are acceptable: Co/ALR, Pigtail and AlumniCon.

Which remediation method was used?*

Co/ALR Pigtail AlumniCon

Does the property have Exterior Insulating Finishing Systems (EFIS) on supporting structures?*

Yes No

Is this used for decorative purposes only and does it take up less than 10% of the structure?*

Yes No

What is the total % of occupancy?*

Throughout the winter is heat maintained to at least 55 degrees or is the plumbing system winterized?*

Yes No

Is the porch or roofline sagging?*

Yes No

Are there any structural issues present?*

Yes No

Foundation, roof, or load bearing walls for example.

Are there piers and stilts? (excluding crawlspaces)*

Yes No

Pier/stilt foundations generally support a home from several feet above the ground, often above or near water

Please Explain: *

Is the location locked and secured?*

Yes No

Are security cameras present? *

Yes No

Is a burglar alarm present? *

Yes No

Renters Insurance Requirement*

Yes No

For occupied locations, I require, enforce, and document, that tenants carry renters insurance.

Other Considerations*

Other Considerations
	Yes	No
Does the property have any common areas?	Other Considerations: Does the property have any common areas? (Yes)	Does the property have any common areas? (No)
Are functioning smoke detectors installed with replacement procedures in place?	Are functioning smoke detectors installed with replacement procedures in place? (Yes)	Are functioning smoke detectors installed with replacement procedures in place? (No)
Are any commercial operations/cooking occurring on the premises?	Are any commercial operations/cooking occurring on the premises? (Yes)	Are any commercial operations/cooking occurring on the premises? (No)
Does the attached parking available exceed 2,000 square feet or 24 spaces?	Does the attached parking available exceed 2,000 square feet or 24 spaces? (Yes)	Does the attached parking available exceed 2,000 square feet or 24 spaces? (No)
Are any of the following the primary heat source: wood-burning stove, kerosene, or portable space heater?	Are any of the following the primary heat source: wood-burning stove, kerosene, or portable space heater? (Yes)	Are any of the following the primary heat source: wood-burning stove, kerosene, or portable space heater? (No)
Does the property have an elevator, lift or hoist on premises?	Does the property have an elevator, lift or hoist on premises? (Yes)	Does the property have an elevator, lift or hoist on premises? (No)
Is Premises kept in a well-maintained status?	Is Premises kept in a well-maintained status? (Yes)	Is Premises kept in a well-maintained status? (No)

Common Areas are any available for use by more than one tenant.

Would you like any of these additional coverages? *

Would you like any of these additional coverages?
	Yes	No
Earth Movement - Protection for Sinkhole and Earthquake Shock perils. Coverage is not available in: AK, CA, FL, HI, or IL	Would you like any of these additional coverages? : Earth Movement - Protection for Sinkhole and Earthquake Shock perils. Coverage is not available in: AK, CA, FL, HI, or IL (Yes)	Earth Movement - Protection for Sinkhole and Earthquake Shock perils. Coverage is not available in: AK, CA, FL, HI, or IL (No)
Equipment Breakdown Coverage - for direct physical damage to the property caused by the breakdown of mechanical systems (HVAC, A/C, Water Heater, etc)	Equipment Breakdown Coverage - for direct physical damage to the property caused by the breakdown of mechanical systems (HVAC, A/C, Water Heater, etc) (Yes)	Equipment Breakdown Coverage - for direct physical damage to the property caused by the breakdown of mechanical systems (HVAC, A/C, Water Heater, etc) (No)
Flood Coverage - for damage to your property caused by rising water from external sources	Flood Coverage - for damage to your property caused by rising water from external sources (Yes)	Flood Coverage - for damage to your property caused by rising water from external sources (No)
Ordinance or Law – for loss caused by enforcement of ordinances or laws regulating construction and repair of damaged buildings	Ordinance or Law – for loss caused by enforcement of ordinances or laws regulating construction and repair of damaged buildings (Yes)	Ordinance or Law – for loss caused by enforcement of ordinances or laws regulating construction and repair of damaged buildings (No)

Would you like to add our Tenant Protector Plan? *

Yes - $60,000 Yes - $100,000 No

Investors alternative to renters insurance. Skip rent, sewer backup and tenant caused negligent losses. $10/month per unit

Would you like to add our Service Line Coverage?*

Yes - $10,000 Yes - $15,000 No

Breakdown of service lines to the property i.e. water, gas, electrical. $5-6/month

Rental Assistance*

What % of your tenants (if any) are subsidized?

Acres*

Is this location professionally managed?*

Yes No

Are you self managing the property?*

Yes No

Would you like to add our PMEO Coverage?*

Yes No

Coverage for claims made against you as the property manager. $2/month per unit.

How often do you monitor the property?*

Who monitors the property, how often?*

Property Manager's Name*

If your business address exceeds 150 miles from the property, your property manager's address must be provided.

Property Manager's Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Property Manager's Phone*

Number of Stories*

Is there a 2nd means of egress on the thirs story and above?

Yes No

Is the top floor of the building livable space?

Yes No

Is there a Mortgagee or Third Party that should be listed on the insurance?*

Yes No

Mortgagee - Third Party Options*

Private lender Partner Traditional Lender/Bank Lease-option or Land contract Named Insured (if different than name on account)

Other:

Mortgagee or 3rd Party Name*

Mortgagee or 3rd Party Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Loan Number?

Mortgagee or 3rd Party Phone

If available

Mortgagee or 3rd Party Phone Fax

If available

Mortgagee or 3rd Party Email

If available

Is the insurance for this location paid through an escrow account?*

Yes No

Does the mortgagee/escrow account need to be billed for this location?

Does the lender require Lender's Loss Payee?*

Yes No

Please upload your lender's requirements if available.

No File Chosen

File uploads may not work on some mobile devices.

Please list any additional information (i.e. additional parties that need to be listed, location notes, owning entities, etc.)

Are there any other structures on the property?*

Yes No

i.e. detached garage, shed, etc.

Do you wish to insure this structure from property damage?*

Yes No

Is the detached structure currently or intended to be occupied?*

Yes No

If yes, the detached structure must be submitted as a separate property

Is the porch or roofline sagging on the detached structure?*

Yes No

Are hazardous or flammable materials being stored here?*

Yes No

Is the detached structure on a separate lease than the main dwelling?*

Yes No

Is there currently a business operating out of the detached structure?*

Yes No

Are there any structural issues on the detached structure?*

Yes No

What is the square footage of this structure?*

What is the year built of this structure?*

What type of structure is it?*

Garage Shed Other

Please Explain:*

'Other Structures' Amount Requested* $

Enter the requested amount of coverage for other structures like a detached garage. If not applicable, enter "0".

Have you had any claims on this property in the past?*

Yes No

Type of Loss?*

Amount of Payout?*

Status of Claim? *

Open Closed

What was the deductible at the time of loss?*

Is this property owner occupied or intended as a primary residence for the owner?

Yes No

Will this location be owner occupied while renovations are happening?

Yes No

Will this location be owner occupied once renovations are complete?

Yes No

Is this a "Subject To" Location? *

Yes No

Is this property a Historical Landmark or on a Historic Registry?*

Yes No

Does this location have burglar bars on any of the windows?*

Yes No

Is this location a row home?*

Yes No

Does this land have any man made structures? *

Yes No

Examples: buildings, plumbing, wiring, drainage ditches, building materials, docks or piers extending over water

Is this land used for business or recreational purposes?*

Yes No

Examples: grazing, ranching, farming, camping, or hunting

Is the property free and clear of trash/debris?*

Yes No

Please provide the borrower's name(s) as listed on the existing mortgage.*

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