SPECIALTY PROPERTY APPLICATION

Applicant’s Name (Legal and Operating):	Broker:	Policy Period: to (12:01 AM)
Applicant’s Address:	How Long in Business:
Other Occupants: Yes, No
Principal Business Address:	Location of Insured’s Property:
Mortgage Name and Address:
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
Year Built:	Smoke Detectors: Yes, No	Name:
Area of building:	Vault or Safe	Alarm system: Burglary
Its name (class):	Name:
Loss and Policy History
Have there been any losses or claims by the applicant in the past 5 years? If yes, complete below: Yes, No
Previous Insurer:	Policy #:
Has any insurer cancelled, declined or refused to renew Commercial Insurance to the Applicant within the past 5 years? Yes, No
Supporting Business: Policy #:	Company:
Coverages Co Form Coverages NP or BF Deductible ($) Coins % Amount of Insurance ($) Rate ($) Premium ($) Building Equipment Stock Contents (E&S) Rental Income N/A Premises Liability N/A $1000 BI&PD Ded. N/A M.R.P: $ Total Premium: $

NOTE: Please Attach or Email a Photo of ALL Buildings
NOTE: Tenant Restriction Endorsement Applies to Rental Properties

Signature:	Date: