Vacant Property Referral Form
Main Contact for Insurance
First Name
Last Name
Best Phone Number
Best Email Address
Name of Property Owner
Individual name(s), Estate, LLC, etc.
Current, Short Term Status of Property
Please Select
Vacant, on the market for sale now or within 30 days
Vacant, pending transfer from estate
Vacant, renovations to start within 30 days
Vacant, renovations to start within 31-120 days
Vacant, renovations required, unknown start
Intended Final Use of Property
Please Select
Put on market and sell
Homeowners Primary (owner occ)
Homeowners Secondary (owner occ)
Rental (tenant occ, annual rental)
Rental (tenant occ, short term rental)
Address of Property to Insure
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (for documents/etc)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Year Built
Best guess if you are not sure
Year of Roof
Best guess if you are not sure
Square Footage
Heated & Cooled area - best guess is fine
Referred By
(Individual name and office)
Is Property Currently Insured?
Please Select
Yes
No
Unknown
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Submit
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