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Information Request for (Tenant Occupied) Rental Insurance

Full Name

Phone #

Are properties held in (Individual Name, LLC, Corp, Partnership, or Trust)?

Date of Birth

Mailing Address

Property Address

Current Occupation

Have you had a Bankruptcy or Insurance Losses within 5 years?

Yes

Effective Date

Current Insured Value $

Year Built

# of stories

Deductible $

Livable square footage

# of smoke detectors

Is this going to be a flip or rental?

Occupancy Date

# of Units

When has the Roof been re-shingled? Year:

Type of Siding?

% of Basement Finished

When has the Electrical Wiring been updated? Year:

Breakers

Fuses

Electrical Amperage #

When has the Plumbing been updated? Year:

Type of Plumbing

Copper

PVC

Galvanized

Is there second floor plumbing?

What’s the condition?

When has the Heating Plant been updated? Year:

Is it Gas Forced Air or Boiler system?

Are there any plans in the future to update the utilities? If so when?

Is there a garage?

Attached or Detached? # of Stalls

Mortgagee Clause

Loan #

Mortgage Amount: $