Apartment Insurance Application Form
Use this form for 5 or more units
For 4 units or less use Landlords form.
Best Viewed in 800x600 Screen Resolution
*Estimated time to complete application 5-10 Minutes*

Reason for insurance request:
New in business Currently in business with no prior insurance
They are Cancelling my Account Account is going to Non-Renew Searching for a better price
Name of Applicant and Mailing Address:
Contact Number:                   Email:
1. Business entity: Individual Joint venture Partnership Corporation Limited Liab. Co.
Other:
2. DBA (Doing Business As):
3. Proposed Effective Date:
4. Home Telephone: Work Telephone: Fax Telephone

5. Email Address:

6. Year business started:
7. Number of Employees: Full time(Include Self) / Number of Employees: Part time

Premises Information
Address: Street, City, State, Zip
City Limits- Inside Outside
Year Built:
Interest- Owner Tenant
Premises Total Square Feet:
Property Details- # of Building, Number of parking spaces, Units and Size.
General Information and underwriting questions

Section A
1. Is the applicant a subsidiary of another entity of does the applicant have any subsidiaries? Yes No
2. Is a formal safety program in operation? Yes No
3. Any exposure to flammables, explosives, chemicals? Yes No
4. Any catastrophe exposure? Yes No
5. Any other insurance with our company or being submitted? Yes No
6. Any policy of coverage declined, cancelled or non-renewed during the past 3 years? Yes No
7. Any past losses or claims relating to sexual abuse or molestation allegations, discrimination or negligent hiring? Yes No
8. During the last ten years, has any applicant been convicted of any degree of the crime of arson? Yes No
9. Any uncorrected fire code violations? Yes No
10. Any bankruptcies, tax or credit liens against the applicant in the past 5 years? Yes No
11. Has the business been placed in a trust? Yes No
Section B
1. Is this a rooming house (common facilities other than laundry)? Yes No
2. Any student renters? Yes No
3. Any aluminum wiring? Yes No
4. Is all wiring connected to circuit breakers? Yes No
5. Are stairs, balconies, sidewalks, driveways or parking lots in good condition? Yes No
6. Are all common doors equipped with self-closing and locking mechanisms? Yes No
7. Are all units and common areas equipped with smoke detectors & fire extinguishers? Yes No
8. Are wood stoves, space heaters or temporary heating units in use on the premise? Yes No
9. Any applicant with tax liens, past due accounts or prior/pending bankruptcy? Yes No
10. Is the building in a flood plain, tornado prone or brush fire area? Yes No
11. Any timeshare, short term or seasonal rentals? Yes No
12. Any bars on windows or security guard hired? Yes No
13. Any government subsidized units/tenants? Yes No
14. Buildings with 50% or more of the residents over 55 years old. Yes No
15. Any Insurance Company recommendation outstanding? Yes No
16. Mortgage ever declined due to property inspection or any other reason? Yes No
17. Is this an owner occupied one family dwelling? Yes No
18. Any community owned electric, water, bridges, dams or septic treatment facilities? Yes No
Please explain any Yes answers:

Prior Carrier Information- Commercial General Liability--- No Previous Carrier
Carrier Name:
General Aggregate:
Each Occurrence:
Property Coverage:
****IMPORTANT DOCUMENTS REQUIRED: For existing businesses you will need to request 4 years of LOSS RUNS from your current insurance provider. Please fax the LOSS RUNS to 619-584-7407. Insurance companies may take up to ten days to provide you with this information****
Loss History
Check this box if you have No Prior losses in the last 4 years:
Lost history information: Please list dates, description of claim, amount paid, and claim status.
Additional Interest or Certificate Holders
Additional Insured | Mortgagee | Lien holder |
Name and Address
Name and Address
General Liability Information
1. Any parking facilities owned/ rented?
2. Is a fee charged for parking? Yes No
3. Recreation facilities provided? Yes No
4. Is there a swimming pool on the premises? Yes No
Please explain any Yes answers:
Property Information

1. If three or more stories does the building have a fire escape or fire tower? Yes No
2. Are periodic checks and repairs made as necessary on all stairs, balconies, sidewalks, driveways or parking lots? Yes No
3. Is the security lighting adequate inside and outside? Yes No
4. Is the building on an historical registrar? Yes No
5. Is the occupancy rate below 80%? Yes No
6. If three or more stories does the building have a fire escape or fire tower? Yes No
7. Is their Management on site? Yes No
8. Is their Maintenance on site? Yes No
9. Does insured live on premise? Yes No
10. Are tenants screened prior to leasing? Yes No
11. Monthly rental for:
One bedroom unit: Two bedroom unit: Three bedroom unit:

Building one
Construction Type
Roof Type
Distance to Hydrant
# Stories
# of Basements
Yr Built

Building Two
Construction Type
Roof Type
Distance to Hydrant
# Stories
# of Basements
Yr Built 		Building Three
Construction Type
Roof Type
Distance to Hydrant
# Stories
# of Basements
Yr Built
Notes:
Building improvements-** Important underwriting question*
Building one
Yr Wiring Updated
Yr Roof Updated
Yr Plumbing Updated
Yr Heating Updated 		Building two
Yr Wiring Updated
Yr Roof Updated
Yr Plumbing Updated
Yr Heating Updated 		Building three
Yr Wiring Updated
Yr Roof Updated
Yr Plumbing Updated
Yr Heating Updated
1. Do you have a Burglar Alarm Yes No
2. Type Fire Alarm
3. Type Premises Fire Protection (Sprinklers, CO2, Etc.) + % of Sprink
Notes:

Requested Coverages- Click here if you don't know

Building Coverage Desired $ (Usually $100-150 a Square foot)
Personal Property Coverage Desired $  
Loss of rent coverage Desired $ (Optional)
Liability Coverage
Recommended 1 million per occ/ 2 million agg
 Per Occurrence$ Aggregate Limit $

Additional Comments:

Referred by:
IMPORTANT NOTE: This form is provided as a convenience to you. We will make a good faith effort to obtain competitive quotes for your review. Depending on the type of business, we may require more information and will contact you if necessary. Your submission of this form DOES NOT guarantee that any binding offers will be forthcoming from insurers we represent.