Vacant Property Quote Request Form

Personal Information
First Name Required Input Required
Last Name Required Input Required
Street Required Street is required.
City Required City is required.
State Required State is required.
ZIP / Postal Code Required Input Required Please enter a valid Postal code.
Primary Phone Number Required Input Required Please enter a valid phone number
E-Mail Address Required You must provide an e-mail address. A valid e-mail address is required.
If answer is YES to any of the following pre-qualifying questions, your property does not meet the requirements for this product. NO NEED TO CONTINUE. Thank you!
Has the applicant had any policy of property insurance cancelled or non-renewed in the past three (3) years for reasons other than vacancy? Required Has the applicant had any policy of property insurance cancelled or non-renewed in the past three (3) years for reasons other than vacancy? is required.	Yes No
Is the applicant currently involved in bankruptcy proceedings? Required Is the applicant currently involved in bankruptcy proceedings? is required.	Yes No
Is the property to be insured undergoing any renovation or construction work of any kind, or is any such work due to commence while insurance is in place? Required Is the property to be insured undergoing any renovation or construction work of any kind, or is any such work due to commence is required.	Yes No
Is the property to be insured subject to mortgage foreclosure proceedings or tax liens? Required Is the property to be insured subject to mortgage foreclosure proceedings or tax liens? is required.	Yes No
Has the property to be insured been condemned or is it scheduled for demolition? Required Has the property to be insured been condemned or is it scheduled for demolition? is required.	Yes No
Existing damage to building(s) to be insured? Required Existing damage to building(s) to be insured? is required.	Yes No
Is the property to be insured subject to more than two (2) mortgages or other encumbrances? Required Is the property to be insured subject to more than two (2) mortgages or other encumbrances? is required.	Yes No
Has the applicant been convicted of the crimes of arson or insurance fraud? Required Has the applicant been convicted of the crimes of arson or insurance fraud? is required.	Yes No
Select Type Required Select Type is required.	Vacant Commercial Vacant Residential
Type of Cover Required Type of Cover is required.	Dwelling (Buildings only) Premises Liability
Value of Building (total value of main building excluding other structure(s) Required Value of Building (total value of main building excluding other structure(s) is required.
Square Footage Required Square Footage is required.
Select Period of Insurance Required Select Period of Insurance is required.	3 months 6 months 9 months Annual
Premises Liability Required Premises Liability is required.	300,000 500,000 1,000,000
Type of Quote Required Type of Quote is required.	select Basic - DP1 Special Form - DP3
Construction Type Required Construction Type is required.	Fire Resistive Frame Masonry non combustible Other
Age of Building or Complete Building Upgrade Required Age of Building or Complete Building Upgrade is required.	0-25 Years 25-50 Years Over 50 Years
Is Vandalism and Malicious Mischief cover required? Required Is Vandalism and Malicious Mischief cover required? is required.	Yes No
Are there any Other Structures to be insured? (If yes, please complete the following details): Required Are there any Other Structures to be insured? (If yes, please complete the following details): is required.	Yes No
All Other Peril Deductible per occurence Optional	select 500 1,000 2,500 5,000
Enter Validation Code Required

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