Lessors Risk Application
This is to secure insurance information for commercial property owners who lease 75% or more of their building to tenants.
I. Applicant Information
Name
*
First Name
Last Name
Doing Business As
ex. Business Name
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Location Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Web Address
*
www.example.com
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Inspection Contact Name
*
Inspection Contact Email
*
example@example.com
Inspection Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Form of Buisiness:
*
Individual
Corporation
Partnership
LLC
Trust
Other
II. Tenant Information
List all tenants’ names, operations and square footage for each
*
Rows
Tenants
Operations
Square Footage
1
2
3
III. Operational & Lease information
How many years has the applicant been at the current location?
*
Are all commercial tenants required to carry insurance?
*
Yes
No
Does the owner/property manager obtain certificates of insurance from all commercial tenants?
*
Yes
No
Does the applicant have a lease in place with all occupants, regardless of ownership?
*
Yes
No
Does the applicant require all commercial tenant(s) to enter and sign written leases?
*
Yes
No
Do the applicant’s leases include an indemnification clause benefiting the applicant?
*
Yes
No
Do leases require tenants to add the applicant as additional insured on their liability policy?
*
Yes
No
Does the applicant occupy part of the premises?
*
Yes
No
If Yes, identify operations:
IV. Building/Property Information
Building Construction
*
Frame
Joisted Masonry
Noncombustible
Masonry Noncombustible
Modified Fire Resistive
Fire Resistive
Year Built
*
Year Updated - Roof
*
Year Updated - Electric
*
Year Updated - HVAC
*
Year Updated - Plumbing
*
Deductible
*
$1,000
$2,500
$5,000
Number of Stories
*
Type of Burglar Alarm
*
Local
Central Station
None
Plumbing Type
*
PVC
Copper
Galvanized
Lead
Other
Age of Roof (Years)
*
Fully Protected by operational sprinkler system (100% coverage)
*
Yes
No
Square Footage of Entire Structure
*
Building Limit
*
V. Liability Section
Number of Apartment Units
*
List of Square Footage of Any Vacant Area
*
Additional Interests (AI = Additional Insured, LP = Loss Payee, M = Mortgagee
*
Rows
Name
Relationship/Interest
Address
City, State, Zip
AI
LP
M
1
2
3
Does the lease require tenant(s) to maintain general liability insurance with applicant as additional insured?
*
Yes
No
Does the lease require tenant(s) to maintain/repair premises, including snow/ice removal?
*
Yes
No
Loss Information
Have there been any property or liability losses in the last five years?
*
Yes
No
If Yes, provide the following information: additional claims or information may be submitted on separate sheet
Rows
Coverage Type
Date of Loss
Description of Loss
Paid ($)
Reserved ($)
Status
1
Property
Liability
Open
Closed
2
Property
Liability
Open
Closed
3
Property
Liability
Open
Closed
Submit
Should be Empty: