New Business Insurance Quote
Apartment Intake Form
Business Name:
*
Contact Name:
*
First Name
Last Name
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address:
*
example@example.com
Are you the owner?
*
Yes
No
Do you hold 100% ownership?
Yes
No
List the Name, Title, and Ownership % of all officers (must equal 100%):
Business Type:
*
Please Select
Corportation
LLC
Partnership
Individual
Trust
Other
Apartment Description:
*
Please respond to the below: - Number of Units: - Number of Stories: - Are pets allowed? Y/N - Are BBQ's allowd on balconies: Y/N - List other features (such as pool/jacuzzi, recreational area, laundry room, etc.):
(Include your web address if you have one)
Physical Location of Apartment Building:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is the square footage of this location?
Are there multiple buildings?
*
Please Select
Yes
No
List buildings and their square footage:
Physical Location same as Mailing Address?
*
Please Select
Yes
No
Mailing Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you utilize a 3rd party property manager?
*
Yes
No
Name of Property Management Company:
Number of years in business:
*
Roof Age
Please Select
0-5 years old
6-10 years old
11-20 years old
21-30 years old
31+ years old
Unknown
Electrical Age
Please Select
0-5 years old
6-10 years old
11-20 years old
21-30 years old
31+ years old
Unknown
Plumbing Age
Please Select
0-5 years old
6-10 years old
11-20 years old
21-30 years old
31+ years old
Unknown
HVAC Age
Please Select
0-5 years old
6-10 years old
11-20 years old
21-30 years old
31+ years old
Unknown
I do not have any of the following at my location: Knob and Tube Wiring, Aluminum Wiring, Federal Pacific/Stab Lok Panels, Zinsco Panels, or Challenger Panels.
*
True
False
Estimated Annual Rents
*
Choose if you have any of the below exposures:
*
Low Income Housing
Subsidized Housing
Student Housing
Assisted Living
None of the above
Provide % of each exposure checked above (must equal 100%):
When does coverage need to take effect?
*
-
Month
-
Day
Year
Do you currently have coverage in place?
*
Please Select
Yes
No
Current Insurance Carrier:
Any Swimming Pools?
*
Please Select
Yes
No
Please confirm:
Fully fenced: Y/N Self latching gates: Y/N Diving Board: Y/N Slide: Y/N Depth markings clearly visible: Y/N Rescue equipment available: Y/N Provide any other detail needed:
Any Playgrounds?
*
Please Select
Yes
No
Describe the playground equipment.
Fire Protection (check any that apply):
*
Hardwired smoke alarms in each unit
Battery operated smoke alarms in each unit
Fully sprinklered interior
Central station fire alarms
Local fire alarms
Emergency lighting in common areas
Aluminum wiring on premises
None of the above apply
Any losses in the last 5 years?
*
Please Select
Yes
No
Explain any losses:
Upload 5 Years of Loss History (if available):
Browse Files
Drag and drop files here
Choose a file
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Reason for shopping insurance:
*
Looking for price relief
Looking for a local agent
Looking to switch agents
Looking for more options
Current insurance is getting non-renewed
New Venture
Other
Additional File Upload (Optional):
Browse Files
Drag and drop files here
Choose a file
**Please upload anything that will help us quote your business. Examples include Declaration Pages to match coverages, plot maps, building photos, etc.
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I contest all the above information is true and accurate.
*
Confirm
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