Condos/Co-Ops Property Information Address for which you need insurance*
Is the mailing/billing address the same as the property address to be insured?* Mailing/billing address*
Interior Square Footage*
Exterior Square Footage
Year Built (Estimate)*
Number of Stories in Building (Estimate)
Unit Resides on Which Floor?
Type of Building Security Please select an option from the dropdown below. 24 Hour Doorperson Part-time Doorperson Virtual Doorperson Buzzer Unsure Yes/No
Are there security cameras in the elevators? Please select an option from the dropdown below. Yes No Unsure
Sprinklers in the Unit? Is the Condo or Co-Op a primary residence ?* Is/Will the Unit Be Rented-to-Others (RTO)? Will the unit be occupied within 30 days after Policy Issuance?* Please provide the reason.
Are any renovations planned within the first 6 months? Would you also like an auto quote?* Combining your coverage for your primary Home and Autos can save 10% per year on both your homeowners & auto insurance premiums
Renters/Tenants Property Information Address for which you need insurance*
Is the mailing/billing address the same as the property address to be insured?* Mailing/billing address*
What type of Property are you renting?* Please select an option from the dropdown below. Condo Co-Op Apartment Single Family/Free-Standing House Single Family/Brownstone House Other
Please describe.*
Interior Square Footage of Property*
Exterior Square Footage of Property (Estimate)
Year Built (Estimate)*
Number of Stories in Building (Estimate)
Floor on which unit resides?
Elevator or walk-up? Please select an option from the dropdown below. Elevator Walk-up
Do The Elevators Have Cameras? Does the property have of the followings? Select all that apply.
Is there a buzzer/secure entry? Are smoke/carbon monoxide detectors are hard-wired or portable?* Distance to the water Please select an option from the dropdown below. Under a 1/4 mile 1/4 mile - 1 mile over 1 mile
Sprinklers in the unit? Central alarm for fire and theft in the unit? Most rentals, condo/coops in NYC do not have a central alarm for fire and theft. The building's alarms don't apply. Central alarm has to be a ADT-type alarm system on the specific unit.
Any roommates? How many?
Would you also like an auto quote?* Combining your coverage for your primary Home and Autos can save 10% per year on both your homeowners & auto insurance premiums
Townhomes/Brownstones/Free-Standing Homes Property Information Address for which you need insurance*
Is the mailing/billing address the same as the property address to be insured?* Mailing/billing address*
Interior Square Footage
Exterior Square Footage
Year Built (Estimate)
How many years have you owned this home?
Number of stories?
Type of Construction Please select an option from the dropdown below Frame Stucco Masonry Brick Fire-Resistive/Superior
What is the primary source of heat? Location of Tank
Roof shape & covering Please select an option from the dropdown below Gable Hip Flat Custom Other
Latest plumbing update
Latest electrical update
Latest roofing update
Latest heating update
Do you require flood insurance? Is there a basement? Is it finished? Is this primary or secondary residence for you? Please Select Option from Dropdown Menu Primary Secondary
Is the home rented or will it be rented to others? Distance to the closest tidal water?
Any wood-burning stove or propane tanks/stoves in home? What is the primary source of heat? Does the property contain any working fireplaces? How many? Please select an option from the dropdown below 1 2 3 4 5 6 7 8 9 10
Are the fireplaces wood-burning or gas?* Please select an option from the dropdown below. Wood-burning Gas Both
Is there a basement? Is it finished? Is there a direct form of egress from the basement to the outside? Is there a fire hydrant within 1,000 square feet of the property? Is there a fire house within 5 miles of the property? What water source is used if there is a fire?
Where is the closest firehouse located?
Is there a fire department paid or volunteer? How many trucks does the fire department have?
How quickly can they arrive at the property?
Is the fire department able to access water at the home from another water source if there is no fire hydrant present? Are the fire trucks equipped to access the water from their sources? Is there a pool or pool house? Is the pool area completely fenced? Is the pool heated? Where is the electrical for the pool kept and are they protected from the elements?
Will you be buying the home outright or will there be a mortgage? Please Select Option from Dropdown Menu Outright Mortgage
Have you reviewed all the risk management concerns of the home with the bank to ensure they will provide financing? Rural homes can be tricky to get financing for - especially if there is no fire hydrant or a fire house nearby.
Does the home have a central alarm for both fire and theft? Would you consider putting one in? Does the home have any superior credits such as a backup generator, alarms for low temperature and shutoff, alarms for water leak detection and shutoff, lightning protection, full-time caretaker?
Would you also like an auto quote?* Combining your coverage for your primary Home and Autos can save 10% per year on both your homeowners & auto insurance premiums
Property Information Address for which you need insurance*
Is the mailing/billing address the same as the property address to be insured?* Mailing/billing address*
Year Built (Estimate)
Number of Stories
Type of Construction Please Select Option from Dropdown Menu Frame Stucco Masonry Brick Fire-Resistive/Superior
Roof Shape & Covering:
When was the roof last replaced?
Latest Plumbing Update
Latest Electrical Update
Latest Roofing Update
Latest Heating Update
What is the primary source of heat? Are there any fireplaces? Please Select An Option From The Dropdown Below Yes No
If so, how many and what are their condition?
Sprinklers in the home? Please Select Option from Dropdown Menu Yes No
Is there a basement? Please Select Option from Dropdown Menu Yes No
Any crawl space? Please Select Option from Dropdown Menu Yes No
Foundation Type (Full Concrete Slab)?
Does the Home Have a Certificate for Retrofitting up to current California Earthquake code? Any Other Structures on Property? Please describe each.
Is there a fire hydrant within 1,000 square feet of the property? Is there an alternative source of water on the property in case of Fire or Explosion? Does the property have its own dry hydrant? Servicing Fire Department in the event of Fire, Explosion or Earthquake:
Distance to nearest Fire Station:
Distance to nearest major Brush:
Have any prior brushfires affected the home, the property or surrounding properties in the general proximity? Is there a pool or pool house? Please Select Option from Dropdown Menu Yes No
Is the pool area completely fenced? Please Select Option from Dropdown Menu Yes No
Is the pool heated? Please Select Option from Dropdown Menu Yes No
Where is the electrical for the pool kept and are they protected from the elements?
Does the home have a Seismic Shut off Valve? Is the entire property fenced around its perimeter? Please describe why
Any canine residents in the household? Please provide number and breed of each
Do you intend to move in immediately after closing or within 30 days of closing? Please describe and please provide the full address where you’ll be living until you move in.
Are any renovations planned immediately after closing? Please describe the work to be done along with a high-level estimate of the total budget. Please attach additional pages as necessary.
Upload additional pages as necessary Do you intend to reside at the property during any planned renovations? Please list the address where you’ll reside during the work and the estimated amount of time you expect to live there.
Does the home have a central alarm for both fire and theft? Please Select Option from Dropdown Menu Yes No
Would you consider putting one in? Please Select Option from Dropdown Menu Yes No
Does the home have any superior credits such as a backup generator, alarms for low temperature and shutoff, alarms for water leak detection and shutoff, lightning protection, full-time caretaker?
Would you also like an auto quote?* Combining your coverage for your primary Home and Autos can save 10% per year on both your homeowners & auto insurance premiums
Do You Own or Rent?* Please select an option from the dropdown below. Own Rent
Please Select Property Type* Please select an option from the dropdown below. Condo/Coop Brownstone Free Standing Home
Do you have a “UL-Approved” home-safe that is bolted down? Does your home/unit have a centrally-monitored alarm system (e.g. Honeywell or ADT) for fire and theft?* IMPORANTNOTE: Within 30 days of policy issuance, the Carrier will require that the Alarm Company provide a Certificate verifying all active, centrally-monitored components of the alarm system
Please select an option from the dropdown below Yes No
Is the home centrally-monitored for fire?* Is the home centrally-monitored for theft?* Year Built (Estimate)*
Number of Stories in Building*
On which floor does your unit reside?*
Does your building have 24-hour security/doorman? Does your building have a buzzer/video doorman/locked-entry system? Sprinklers in the unit? Would you also like an auto quote?* Combining your coverage for your primary Home and Autos can save 10% per year on both your homeowners & auto insurance premiums
Coverage Information What is the estimated total value of your "Everyday” Personal Contents?*
Includes Furniture, Home Furnishings, Clothing, Shoes, Handbags, Accessories, Luggage, Electronics, Supplies for the Kitchen, Bedrooms & Bath, etc, and Personal Property.
Are there any categories of Valuable Articles Coverage (VAC) that you are you interested in Insuring (please select all that apply)?* Total Value of Jewelry/Watches*
Number of Jewelry/Watches
Full description of the item(s) Please include pertinent details including size, dimensions, clarity, year, special details, etc.
Total Value of Fine Art*
Number of Fine Art Pieces
Includes coverage for paintings, illustrations, photography, sculpture, abstract/interactive/3-dimensional pieces, antique furniture, imported Persian rugs, etc.
For each collection piece to be insured, please provide a brief itemized description (e.g., including carat weight, color, clarity, dimensions, manufacturer, artist, designer, year produced, etc.):
Total Value of Wines*
Number of Wines
Total Value of Musical Instruments*
Number of Musical Instruments
Total Value of Silver Pieces*
Number of Silver Pieces
Total Value of Sports Memorabilia*
Number of Sports Memorabilia
Total Value of Other Valuables Collections*
Number of Other Valuables Collections
When traveling, what is the total value of your jewelry/watch collection taken with you?*
How do you protect your jewelry/watches when you travel?* Select all that apply.
Worn/In Sight at All Times Hotel Safe Home Safe Locked Cabinet at Home Safe-Deposit Box
Motor Vehicle Property Information Address*
Do you have a separate garaging address? Garaging Address*
Is the mailing/billing address the same as above?* Mailing/billing address*
Coverage Information How many motor vehicles to be insured?*
Is this your first automobile to be insured?* Have you had continuous auto coverage over the past 12 months with no lapse in coverage of more than 30 days?* Please Describe.*
Motor Vehicle(s) Type: Year, make and model for each vehicle to be insured:*
17-Digit Vehicle Identification Number (VIN) for each vehicle to be insured
Have you already taken delivery of each motor vehicle listed?* Current auto insurer
How many years have you insured the vehicle with your current carrier? (Please include your Declaration Pages from your current Motor Vehicle Insurance Policies)
Declaration Pages
Have you experienced a lapse in coverage of 30 days or more within the last 12 months? Please Describe*
Motor Vehicle Insurance Related Losses/Claims Any losses/claims/accidents/violations in past 5 years?* Please Select Option from Dropdown Menu Yes No
Please Describe*
Have you had continuous motor vehicle coverage over the past 12 months?*
Who is your current carrier?*
How long have you been insured with your current automobile insurer?*
What are the current injury body limits they carry?*
How many miles do you drive annually?*
Do you own or rent?* Please Select Option from Dropdown Menu Own Rent
What is the expected ownership structure of the vehicle?* Please Select Option from Dropdown Menu Own Outright Finance Lease
Please provide Loss Payee Information:* (Loan or lease number, bank or leaseholder name, address, phone & fax numbers)
Watercraft Underwriting Information What type of insurance would you like to have?* Please select an option from the dropdown below Sailboat Motorboat (26ft or less) Yacht/Motorboat (greater than 26ft Personal Watercraft (waverunner, etc.)
Is the principal operator over 25 years of age?* Is this a houseboat in a salt water/coastal area?* Can the watercraft go faster than 75mph?* Does any operator have any criminal convictions in the past 5 years?* (ex. Arson, Burglary, DUI)
Please describe*
Is this watercraft chartered to others (CTO)?* Please describe*
Property Information/Flood Zone Determination What Type of Property Is Being Insured?* Please select an option from the dropdown below. House Brownstone Condo Co-Op Investment Property
Date of Original Construction*
Type of Construction*
What is the heated square footage (estimate) of the primary structure to be insured for flood?*
Up to 5 numeric digits required.
What is the square footage (estimate) of each additional structure on the property?
Structure Does the structure have an attached or detached garage?* Please indicate if you have any of the following appliances beneath the elevated floor. Select all that apply.* Please indicate the value of the appliances indicated above.*
Please indicate if you have any of the following machinery and equipment beneath the elevated floor. Select all that apply.* Please indicate the value of the machinery and equipment indicated above*
Beneficiary Information Number of Beneficiary*
Name*
Relationship*
Address*
Is the mailing/billing address the same as the property address to be insured?* Mailing/billing address*
Percentage*
Coverage Details Coverages* Objectives for Securing Life / Disability Insurance*
What Coverage Amount Would You Like?* Please Select An Option From The Dropdown Below $0 - $250,000 $250,000 - $500,000 $500,000 - $1,000,000 $1,000,000+
Please list any chronic medical conditions or diseases (e.g., Diabetes, Heart Disease, Cancer, etc.,)*
Do you drink alcohol or smoke marijuana? Please include frequency amount estimate*
Have you ever been diagnosed & treated for Depression, Anxiety, Addiction or another medically-diagnosed condition?* Are your parents alive?* Please list their ages and any chronic medical conditions they experience*
Please indicate when they passed and the cause of death*
Does cancer, diabetes, high-blood-pressure, high cholesterol, heart disease or other chronic condition run in your family or origin?* Basic Business Information Effective Date for the Policy* Date of Closing or Expiration Date of Existing Policy Coverage* Full Business Name*
Federal Tax ID (EIN)*
Federal Employee ID*
Type of Business* Please select an option from the dropdown below. Select Option from Dropdown Menu Corporation S-Corp LLC Individual/Sole Proprietorship
Full Business Address*
Is mailing address different from the business address?* Full Mailing Address*
Phone Number*
Fax
Email*
Website Address*
Contact Name*
First
Last
Title*
Year Business Began*
Years of Experience in Field*
Full Description of the Business Please Describe*
Coverage Limits Requested Commercial General Liability*
Umbrella Liability*
Business Personal Property* (e.g., Office Furniture, Equipment, etc.)
Computer Hardware & Software*
Commercial Autos* Please include number/type & VIN for each vehicle
Building Information Year building was built?*
Square footage occupied?*
Number of stories in the building*
Do you own or rent your space?* Select Option from Dropdown Menu Own Rent
Sprinklers in your suite? Central Alarm in your suite for fire and theft? 24-hour security? Latest Plumbing Update*
Latest Electrical Update*
Latest Wiring Update*
Latest Roofing Update*
Any Other Locations?* Please list your other locations*
Business Revenue & Payroll Information Payroll Needed For Workers Compensation & Disability Required By State Labor Laws.
Actual Annual Sales 2016*
Projected Annual Sales 2017*
Actual Annual Payroll 2016*
Projected Annual Payroll 2017*
Total Number of Employees*
The Number of Full & Part-Time Employees*
How Many Male Employees*
How Many Female Employees*
How Many Sales Employees*
How Many Clerical Employees*
Landlord Information To add landlord as an additional insured.
Name*
Contact Person*
First
Last
Address*
Phone*
Email*
Schedule of Hazards Address for which you need insurance*
Is the mailing/billing address the same as the property address to be insured?* Mailing/billing address*
Description*
Products/Completed Operations How many products/completed operations? Product*
Annual Gross Sales*
Intended Use*
Principal Components*
Product Two*
Annual Gross Sales*
Intended Use*
Principal Components*
Product Three*
Annual Gross Sales*
Intended Use*
Principal Components*
Explain all "yes" responses (For all past or present products or operations) Please attach literature, brochures, labels, warnings, etc.
Does applicant install, service, or demonstrate products? Please describe.
Foreign products sold, distributed, used as components? Please attach ACCORD 8:15.
Guarantees, warranties, hold harmless agreements? Please describe.
Products related to aircraft/space industry? Please describe.
Products recalled, discontinued, changed? Please describe.
Products of others sold or re-packaged under applicant label? Please describe.
Products under label of others? Please describe.
Vendors coverage required? Please describe.
Does any named insured sell to other named insureds? Please describe.
Additional Interest/Certificate Recipient Name (As It Should Appear on Policy)*
Ms. Mr. Mrs. Miss Dr. Hon. Rev. Fr. Dame Sir
Prefix
First
Middle
Last
Suffix
Address*
Is the mailing/billing address the same?* Mailing/billing address*
General Information Explain all "yes" responses (For all past or present products or operations)
Any medical facilities provided r medical professionals employed/contracted? Please describe.
Any exposure to radioactive/nuclear materials? Please describe.
Do/have past, preset or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting or hazardous material? (ex. landfills, wastes, fuel tanks, etc.) Please describe.
Any operations sold, acquired, or discontinued in last five years? Please describe.
Do you rent or loan equipment to others? Equipment
Type of equipment Please select an option from the dropdown below Small tools Large equipment
Instruction given?
Equipment
Type of equipment Small tools Large equipment
Instruction given?
Any watercraft, docks, floats owned, hired or leased? Please describe.
Any parking facilities owned/rented? Please describe.
Is a fee charged for parking? Please describe.
Recreation facilities provided? Please describe.
Are there any lodging operations including apartments? Number of apartments
Total apartment area (Sq. Ft)
Describe other lodging operations
Are social events sponsored? Please describe.
Are athletic teams sponsored? Type of sport
Contact sport?
Age group Please select an option from the dropdown below 12 & Under 13 - 18 Over 18
Type of sport
Contact sport?
Age group Please select an option from the dropdown below 12 & Under 13 - 18 Over 18
Any structural alterations contemplated? Please describe.
Any demolition exposure contemplated? Please describe.
Any applicant been active in or is currently active in joint ventures? Please describe.
Do you lease employees to or from other employers? Lease to
Workers Compensation Coverage Carried?
Lease from
Workers Compensation Coverage Carried?
Is there a labor interchange with any other business or subsidiaries? Please describe.
Are day care facilities operated or controlled? Please describe.
Have any crimes occurred or been attempted on your premises within the last three years? Please describe.
Does the business' promotional literature make any representations about the safety or security of the premises? Please describe.
Signature Applicant's Signature*
Date*
Commercial Motor Vehicle Property Information Address*
Do you have a separate garaging address? Garaging Address*
Is the mailing/billing address the same as above?* Mailing/billing address*
Coverage Information How many commercial motor vehicles to be insured?*
Is this your first commercial automobile to be insured? Have you had continuous commercial auto coverage over the past 12 months with no lapse in coverage of more than 30 days? Please Describe.*
Commercial Motor Vehicle(s) Type: Year, make and model for each commercial vehicle to be insured:*
17-Digit Vehicle Identification Number (VIN) for each commercial vehicle to be insured
Have you already taken delivery of each commercial motor vehicle listed?* Current commercial auto insurer
How many years have you insured the commercial vehicle(s) with your current carrier? (Please include your Declaration Pages from your current Motor Vehicle Insurance Policies)
Declaration Pages
Have you experienced a lapse in coverage of 30 days or more within the last 12 months? Please Describe*
Commercial Auto Insurance Related Losses/Claims Any losses/claims/accidents/violations in past 5 years?* Please Select Option from Dropdown Menu Yes No
Please Describe*
Have you had continuous motor vehicle coverage over the past 12 months?*
Who is your current carrier?*
How long have you been insured with your current automobile insurer?*
What are the current injury body limits they carry?*
How many miles do you drive annually?*
Do you own or rent?* Please Select Option from Dropdown Menu Own Rent
What is the expected ownership structure of the vehicle?* Please Select Option from Dropdown Menu Own Outright Finance Lease
Please provide Loss Payee Information:* (Loan or lease number, bank or leaseholder name, address, phone & fax numbers)
Property Information Address for which you need insurance*
Is the mailing/billing address the same as the property address to be insured?* Mailing/billing address*
Property To Be Insured* Please Select an Option From The Dropdown Below Residential Habitational
Year Built*
Overall Property Condition* Age of Roof*
Roof Type* Select Option from Dropdown Menu Flat Roof Pitched Roof
Latest year of plumbing system updates*
Latest year of heating system updates*
Type of heat Location of Tank*
Do you hire an outside company service firm to maintain the oil tank?* How often is the oil tank serviced? Please select an option from the dropdown below. Annually Monthly Quarterly Semi-Annually
Are any of the following heat sources present in the units?* Fireplaces (wood/coal), wood pellet stoves, coal stoves, gas on gas stoves or space heaters
Select Option from Dropdown Menu Yes No
Does the building employ outside contractors for essential services(e.g., Maintenance, Snow Removal, Landscaping, etc.)* Select Option from Dropdown Menu Yes No
Does the property contain any aluminum wiring?* Select Option from Dropdown Menu Yes No
Are there any Stab Lok circuit panels or Stab Lok circuit breakers conttained in the electrical system?* Select Option from Dropdown Menu Yes No
Total Number of Units*
Number of Floors*
Percentage Occupied*
For Condo/Co-ops, list number owner occupied*
Any student occupied units?* Select Option from Dropdown Menu Yes No
Number of Units*
Any rent subsidized units?* Select Option from Dropdown Menu Yes No
Number of Units*
Any retirement, assisted living or senior units?* Select Option from Dropdown Menu Yes No
Number of Units*
Any vacant units?* Select Option from Dropdown Menu Yes No
Number of Units*
Describe tenant's care for property*
Crime/Vandalism/Malicious Mischief Exposure Are any neighboring buildings vacant or under renovation?* Select Option from Dropdown Menu Yes No
If yes, please describe.*
Neighborhood is:* Comments*
Is the building undergoing renovations or repairs currently/planning?* Select Option from Dropdown Menu Yes No
Describe*
Are there smoke/carbon monoxide detectors and meet current local code? (ask jay)* Select Option from Dropdown Menu Yes No
Are there hardwired smoke detectors within units?* Select Option from Dropdown Menu Yes No
How often are smoke detectors serviced and batteries replaced?* Are there hardwired smoke detectors within common areas?* Select Option from Dropdown Menu Yes No
Are there hardwired smoke detectors within units?* Select Option from Dropdown Menu Yes No
Is there emergency lighting or signage?* (required 4 stories are more)
Select Option from Dropdown Menu Yes No
Are window guards provided?* (if required by code - i.e NYC)
Select Option from Dropdown Menu Yes No
Is building sprinklered?* Select Option from Dropdown Menu Yes No
Where are the sprinklers are located?* Please describe.*
Are barbecue grills allowed on decks, porches or balconies?* We require 15 ft. clearance from building.
Select Option from Dropdown Menu Yes No
Which grills are allowed for barbecue? Are carbon monoxide detectors working?* (if required by code)
Select Option from Dropdown Menu Yes No
Please Explain*
How many means of building egress? Is there a secondary means of egress?* Select Option from Dropdown Menu Yes No
Describe secondary means of egress*
Liability Exposures Does insured own any other property or conduct any operations under this name?* Select Option from Dropdown Menu Yes No
Please Describe*
Has insured ever acted as a general contractor or sub contractor under this name?* Select Option from Dropdown Menu Yes No
Are any of the following on the premises?* Are there any restrictions on type, number of size of dogs allowed?*
Is the building presently for sale?* Select Option from Dropdown Menu Yes No
Year Purchased*
Purchase Price*
Annual Building Revenue*
Condo Fees (if applicable)*
Please provide front and rear photographs of the building with your submission. This will expedite our underwriting and analysis and response.
If multiple buildings are being covered, please provide a plot plan and/or distances between insured buildings.*
Workers Compensation
Employee Work Environment
What percentage of employees have been with you more than 3 years?*
What percentage of employees are covered by health benefits that you make available?*
Do you conduct the following for prospective employees?* Do all supervisory personnel have necessary language skills?* Select Option from Dropdown Menu Yes No
Safety Management
Is there a formal written safety program in place?* Select Option from Dropdown Menu Yes No
Do you hold regular safety meetings?* Select Option from Dropdown Menu Yes No
Are supervisors held accountable for safety, with incentives provided for safe practices?* Select Option from Dropdown Menu Yes No
Are all costs (e.g., loss of production, training,e tc.) associated with all WC accidents reviewed with all supervisors?* Select Option from Dropdown Menu Yes No
How frequently are self-inspections performed?*
Claims Management
Do you have a designated injury coordinator(s) who is point of contact for injured employees?* Select Option from Dropdown Menu Yes No
Are they fully trained in reporting claims, following up with injured workers, working with out claims personnel, and return-to-work opportunities?* Select Option from Dropdown Menu Yes No
How frequently do they contact an out-of-work, injured worker?*
How frequently do supervisors/managers contact an out-of-work injured worker?*
Is there modified or light duty work available for an injured employee?* Select Option from Dropdown Menu Yes No
Other
Are security services provided?* Select Option from Dropdown Menu Yes No
Do employees live on premises?* Select Option from Dropdown Menu Yes No
Does applicant perform any chimney cleaning, roofing or rain gutter repairs?* Select Option from Dropdown Menu Yes No
Does applicant perform any tree trimming?* Select Option from Dropdown Menu Yes No
Does applicant perform any exterminating services?* Select Option from Dropdown Menu Yes No
