VACANT BUILDING/BUILDING UNDER RENOVATIONS APPLICATION 

Requested policy term: 3mo___ 6mo___ 12mo___ Requested Effective Date: ___/___/___ Prior Exp. Date:___/___/___ 

Applicant Signature (Required to Bind): ________________________________________________ Date: _____________ 

Prior Carrier: ___________________________    Has coverage been declined/cancelled/non‐renewed?   YES      NO 

Applicant/Co‐Applicant Information  Applicant: __________________________________    Telephone Number: (        ) ______ ‐ _______ 

Mailing Address: _____________________________________________________________________________________________________ 

Occupation: __________________________________ Employer Name: __________________________________ Years w/ Employer: ______ 

Rating/Underwriting Information  Location Address:  ____________________________________________________________________    

How long has applicant owned building? _________ If purchased w/in past year, indicate purchase price $_____________________________  

Prior use of building when occupied: ____________________________ Intended Disposition: _______________________________________ 

Please confirm weekly checks are made to the premises?   YES        NO        By whom? ______________________________________________ 

Protection Class: ____ Distance to; Hydrant: ________ Fire Dept: _______ Lot Size (acres): _____Year Built: ______ Sq Footage: __________ 

NUM OF AMPS (ELEC SYST) 

CIRCUIT BREAKERS  FUSES  KNOB & TUBE OR ALUMINUM WIRING

YES        NO   YES        NO   YES        NO  

Is electricity maintained year round?   YES       NO       When were wiring, heating, plumbing & roofing last fully updated?   Wiring: _______ Heating: _______Plumbing: _______Roofing: _______ 

Please confirm whether all pipes are drained and water is shut off during winter months.  YES        NO      

If NO, what is the primary source of heat? ___________________    Is fuel setup for automatic delivery?  YES      NO  

Property Coverage  Desired Coverage Limit 

ACV of Existing Structure  $ 

ACV of Amount of Renovations To Be Conducted  $ 

Personal Property  $ 

Premises Liability (please select) 

Medical Payments (please select)

Check ALL boxes below that DEFINE the work being done:  (If additional space is needed, attach separate sheet.)   Replacing Bathroom Fixtures   Replacing Roof  Replacing Windows   Siding or Painting Exterior  Replacing Kitchen Cabinets   Replacing Floors  Replacing Exterior Doors   Gutting the Premises  Replacing Plumbing/Heating/Electrical   Painting  Other (Specify):

Will ANYONE other than the applicant be conducting renovations?   YES       NO       (All subcontractors must have a CGL policy in force.) 

LOSS HISTORY (Last 3 years):   

Year  Payout Amount  Description – Damages Repaired? 

MORTGAGEE CLAUSE:  ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ 

Retail Agent Information 

Agency: _________________________________________________ Mailing Address: __________________________________________Phone: (        ) _______ ‐ _________  Fax: (     ) _______ ‐ _________  Contact E‐mail: ___________________________________________