* Agency Name:    * Agency #:    E-mail Address:

* Contact:    * Policy Term:3 Months4 Months5 Months6 MonthsOver 6 Months (Submit)

* Applicant Name:

Mailing Address:    * City:    * State:    Zip Code:

* VACANT: Current Value $  * RENOVATION: Purchase Price $   * Value of Improvement: $   * New Value $

Location to be insured:

* Deductible:5001,000    Year Built:   * Protection Class:Select One12345678910   * Construction:Select OneFrameMasonryNoncombustible 

Number of stories:    Square Footage:    Age of Roof: 

Value:Perils-Basic with VMM    Coinsurance:80%90%100%    How long has applicant owned property at this location:

How long has building been vacant:    Reason for Vacancy:

Intended disposition of property (i.e., sell, rent, occupy):

Prior Occupancy:    Describe general condition of building:

How often are regular checks made to the property and by whom:

Building Secured:Yes    No    Bankruptcy Status:

Mortgagee:

* Previous Carrier:

* Loss History:

Other Pertinent Information: