Vacant Property Insurance Application

Vacant Property Insurance Application
Name*

First NameLast Name
Date of Birth*
Co Applicant (If Applicable)

First NameLast Name
Date of Birth
Entity Name or Trust Name
If Applicable
Entity Type
Phone Number*
Include Area Code
Email*
example@example.com
Type of Property To Quote*
Desired Policy Term*
How Many Acres*
Is The Land Fenced & No Trespassing Signs Posted?

YesNo
Are Any Of The Following Exposures Present

Open Body of WaterActive WellsUnderground Storage TanksAny Structure Exceeding 500 Sq FtAny Portion Of The Land LeasedAny Farming/Agriculture ExposureLand Used For HuntingGrounds Used For Burial
Mailing Address*
Please Provide Complete Address
Property Address*
Please Provide Complete Address
Underwriting Questions
Is This Property Currently Insured?*

YesNo
If Yes Provide Carrier Name & Exp Date
Will There Be Multiple Structures To Quote*

YesNo
Are All Structures Vacant?*

YesNo
Any Pre-Existing Damage*

YesNo
Length of Vacancy*

Less Than 6 mo6mo to 1yrMore Than 1yrUnknown
Length of Ownership*

New PurchaseLess Than 6 mo6mo to 1yrMore Than 1yr
Will There/Is There A Loan On The Property*

YesNo
Purchase Price
Closing Date

MonthDayYear
Date
Are Any Renovations Planned? (If Yes Please Provide Details At The End of The Application)*

YesNoUnknown At This Time
Will Any Work Be Structural In Nature?

YesNoUnknown
Will Work Be Completed By A Licensed Contractor?

YesNo
Estimated Cost of Renovations
Estimated Length Of Construction

1-3 months4-6 months6-9 months9+ months
Provide Detailed Description of Renovations Planned
Are Any Of The Following Present On The Premises*

N/APoolFireplaceLake/PondFarming ExposureActive WellUnderground Storage TankCast Iron PlumbingKnob & Tube ElectricalAny Animals
Does/Will The Property Have Active Utilities

YesNo
How Often Do You Check On The Property?

DailyWeeklyBi-WeeklyMonthlyN/A 3rd Party Checks on Property
Do You Know How Much Coverage You're Looking For?

YesNo
Dwelling/Property Coverage Amount
Other Structures Coverage Amount
Desired Deductible
Desired Liability Limits
Settlement Option

Actual Cash Value (ACV)Replacement Cost (RC)Agreed Value
Additional Coverage Options

Personal PropertyExcess LiabilityVandalism/Malicious MischiefWater BackupFloodRoof Replacement Cost Settlement
Provide Any Additional Information Such As Property Details, Description of Pre-Existing Damage, Minimum Coverage Requirements, etc...
For Multiple Locations Please Upload Property Schedule

Upload File(s)

Cancelof
Please note additional information and/or a supplemental application may be required in addition to the information provided prior to receiving a quote. Once your submission has received a member of CityScape Insurance will be in contact within 1 business day. If you require immediate coverage please contact our office and we will place a RUSH on your submission to underwriting.
Please verify that you are human*
P: (602) 888-1732 | E: info@cityscapeinsurance.com

IT IS UNDERSTOOD AND AGREED THAT THE COMPLETION OF THIS APPLICATION SHALL NOT BE BINDING EITHER TO THE PROPOSED INSURED OR TO THE COMPANY UNTIL ACCEPTED BY THE COMPANY OR COMPANIES IN WRITING.
Tentative Effective Date Needed By*

MonthDayYear
Date
AZ Lic # 1800011010 | CO: 598458 | FL Lic # W519333 | NM Lic # 1800012011 | TX Lic # 1995214
Should be Empty:

Vacant Property Insurance Application

Underwriting Questions