Vacant Building Insurance Quote Form

Page Insurance, Ltd

102 Boston Street

Guilford, CT 06437

(203) 453-5258

info@pageins.com
Type of Entity

Sole ProprietorshipLimited Liability CompanyCorporationPartnership
Name of Applicant*
Your Name*

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Phone Number*
E-mail Address
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Inspection Contact*
Years in Business/Owned
Effective / Closing Date*

MonthDayYear
Policy Term*

3 Months6 MonthsAnnual
Address of Building to be Insured:*

Street Address

Street Address Line 2

CityState

Zip Code
Previous Carrier (if applicable)
Any Claims in past (5) years?*

YesNo
Describe Claims/Loss History (past 5 years)
Reason for Vacancy*
How long has property been vacant?*

Coverage / Property Limits Requested*

	Limit of Insurance	Cause of Loss	Valuation	Deductible
Building Coverage
Personal Property Coverage

Other Coverages / Limits Requested
Purchase Price
Mortgagee
General Liability Coverage Limits*

100,000 / 100,000300,000 / 300,000500,000 / 500,0001,000,000/1,000,000
Protection Class (if known)
Square Footage of Building*
Building within 1,000 feet of hydrant?*

YesNo
Building within 3 miles of fire station?*

YesNo
Construction*

FrameMasonryOther
Year Built*
Age of Roof*
Number of Stories*
Year of Last Plumbing Upgrade*
Type*

FullPartialN/A (Under renovation)
Year of Last Wiring Upgrade*
Type*

FullPartialN/A (Under renovation)
Year of Last Heating Upgrade*
Type*

FullPartialN/A (Under renovation)
Year of Last Roofing Upgrade*
Type*

FullPartial
Are utilities operational water and/or electric?*

YesNo
Physical Condition of Building*

PoorAverageAbove AverageExcellent
How is building Secured (check all that are applicable)*

Locked / Boarded / SecuredSecurity SystemCaretakerVisited Daily by ownerNeighbors watch house
Are renovations going to take place?*

YesNo
Cost of Renovations (if any)
Description of Renovations (if any)
Who will be doing renovations?

InsuredContractor
Does Contractor have General Liability Coverage in force?

YesNo
Will Named Insured secure Certificates of Insurance?

YesNo
Is there a pool on premises?*

YesNo
If yes:

Above GroundBelow Ground
Is the pool fenced?

YesNo
What do you plan to do with the property?*

SellRentLeave VacantOther
If other, please specify:
File Attachment (if applicable):

Browse Files

Cancelof
Submitted by*

Agency StaffApplicantOther
Agency Staff
Email
example@example.com
Date

MonthDayYear
Date
Should be Empty: