SPECIALTY PROPERTY- VACANT APPLICATION

Applicant’s Name (Legal and Operating):	Broker:	Policy Period: to (12:01 AM)
Applicant’s Address:	Occupancy: Applicant Yes, No
Other Occupants: Yes, No
Location of Insured’s Property, Same as home	How Long in Business:
Construction Details
Walls:	Number of apartments:	Electrical: Fuses, Breakers
Roof:	Interior Finish:	Hydrant Protected? Yes, No
Storeys (excluding basement):	Auto Sprinklers: Yes, No	Fire hall? Yes, No
Basement: Yes, No	Automatic CO2: Yes, No	Distance from building(km):
Heating:	Number of Extinguishers:	Alarm system: Fire Name:
Year Built:	Smoke Detectors Yes, No
Area of building:	Vault or Safe	Alarm system: Burglary
Its name (class):	Name:
Updates: Roof: Heating: Electrical: Plumbing:
Loss and Policy History
Previous claims in the past 5 years? Yes, No Describe:
Previous Insurer:	Policy #:
Has any insurer cancelled, declined or refused to renew Commercial Insurance in the past 5 years? Yes, No
Supporting Business: Policy #:	Company:
Mortgagee: Name:
Address:
Coverages
Covers	Coverages	Names Perils	(Ded 5%) Min $2500	Coins %	Amt. Of Insurance	Rate	Premium $
1	Building	Yes
2	Premises Liability	N/A	$1000 Bi&PD Ded	N/A
Note: Riot, Vandalism, and Malicious acts are excluded We write 3 month policies subject to min premium of $750 for the 3 month term Cover is limited to 75% of the act determine mortgage amount $ We do not write risks that have been vacant for more than 12 months Confirm that the property will be checked every 4 days (96 hours) ans the name of the perty responsible for the check Confirm police and fire dept have been advised and proper steps taken to secure the property and utilities have been disconnected

Please attach or e-mail photos of all buildings

Signature:	Date: