Vacant Property

Last update: 03/21/2008

Vacant Property Quote Form

Please complete the following form and click the "Send Quote" button to submit
for a free Vacant Property Insurance Quote.

VACANT PROPERTY QUOTE FORM
First Name:
Last Name:
Phone Number:
Fax Number:
E-Mail Address:

PROPERTY INFORMATION
Property Address:
Property City:
Property State:
Property Zip Code:
How Many Months Has The Property Been Vacant?
What Date Did The Property Become Vacant?
Why is the Property Vacant?
What Steps have you taken to make sure the Property is safe and secure?
Give a Good Description Regarding the Physical Condition of the Property?
How Many Months Will The Property Be Vacant?
How Many Units Are In The Building:
Year Built:
Date You Purchased The Property:
Garage Description:
How Many Stories:
If Two Stories, Ground Floor Square Footage:
Total Square Footage of The Building:
Construction Type:
Roof Type:
Roof Updated:	yes no
If Yes, Year Roof was Updated:
Property Topography:
Protection Distance:
Is The Building in the Brush?	yes no
Is there a Brush Hazard within (1) mile of The Building?	yes no
If yes, has the Brush been cleared by 250 feet from all sides of The Building?	yesno
Smoke Alarm:	yesno
Fire Extinguisher:	yesno
Deadbolts:	yesno
Electrical Updated:
Circuit Breakers:	yes no
Copper Wiring:	yes no
Heating - Air Conditioning, How Old?:
Heating - Air Conditioning, Thermostatically Controlled?:	yes no
Energy Source:
Heating - Air Conditioning, Central?	yes no
Plumbing Updated:	yes no
If Yes, Year Plumbing was Updated:
Copper Plumbing:	yes no
Fire District:
Current Insurance Company:
Losses-Claims in the last 5 years:
*If Yes, Date, Amount Paid & Description of Each* Loss-Claim**

COVERAGE INFORMATION
Dwelling Amount (Coverage A):
Other Structures (Coverage B):
Personal Property (Coverage C):
Loss of Use (Coverage D):
Premise Liability (Coverage E):
Policy Deductible: