Vacant Land Insurance Quote Form

Page Insurance, Ltd

102 Boston Street

Guilford, CT 06437

(203) 453-5258

info@pageins.com

Name

Contact Name

First NameLast Name

Phone Number

Area CodePhone Number

Contact Email

Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code

Website

yoursite.com

Applicant Is:

Other

Limit Requested:

Policy Period:

In which state is the property to be insured?

Street Address

Street Address Line 2

State / Province

Has the applicant had any claims or losses in the past 3 years at the land to be insured?

Has the applicant had any policy of liability insurance refused, cancelled or non-renewed in the past 3 years?

Has / Is the Applicant currently involved in bankruptcy proceedings?

Is the land to be insured subject to more than two mortgages or other encumbrances?

Does the land to be insured exceed 500 acres?

Is the land to be insured located in a landslide, forest fire or brush fire area?

Is the land to be insured leased to others?

Is the land to be insured used as a dump site, landfill or are there any potential environment exposures or hazards?

Are there any of the following on the land to be insured: (Check all that apply)

Are there any activities taking place on the land to be insured, including buy not limited to: (Check all that apply)

Are there any water hazards on the land to be insured? Including but not limited to lakes, rivers and reservoirs.

Does water exceed an area greater than an acre?

Are there any levees, dams or reservoirs on the land to be insured?

Are "No Swimming" signs clearly visible around any lake or body of water?

Are "No Trespassing" signs clearly visible at all entries to the vacant land to be insured?

Address of Location 1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Number of Acres

Lake Acreage

Address of Location 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Number of Acres

Lake Acreage

Period of Coverage

Size of Land (in acres)

What was the prior use of the land?

What are the future plans for use of the land?

Is the property fence / posted?

Premises liability limits

Requested Effective Date

Date

Proposed Expiry Date

Date

Medical Payments

Is TRIPRA coverage required?

Have there been any insured or uninsured losses or claims at the location to be insured?

Please describe all prior losses or claims including the date, the nature of occurrence, the status, the amount and whether the damage has been repaired:

NOTICE OF INSURANCE INFORMATION PRACTICES. In connection with this application for insurance (and subsequent policy renewals), your personal information may be collected from persons other than you and without your authorization (e.g., credit reports). You have the right to review your personal information in our files and may request correction of any inaccuracies contained therein. A more detailed description of your rights and our practices regarding such information will be available upon request and you may contact your agent or broker for instructions regarding how to submit this request to us.

Any person who knowingly files an application for insurance or a statement of claim with materially false information with the intent to defraud an insurance company or another person is committing a fraudulent insurance act. Moreover, any person who has concealed material facts for the purpose of providing misleading information is also committing a fraudulent insurance act. These acts are crimes and subjects the person to criminal and [NY: substantial] civil penalties. (Not applicable in CO, FL, HI, MA, NE, OH, OR, or VT; in DC, LA, ME, TN, VA and WA insurance benefits may also be denied). In Florida, it is a third-degree felony to knowingly file a statement of claim or any application containing false, incomplete, or misleading information with the intent to injure, defraud and/or deceive any insurer.

The undersigned is an authorized representative of the applicant and acknowledges that reasonable inquiry has been made to obtain the information on this application. He/she acknowledges that the answers are true, correct and complete to the best of his/her knowledge.

Applicant's Signature (Owner or Officer)

Date

MonthDayYear

Broker's Signature

Date

MonthDayYear

Notes

Submitted by

Other

Agency Staff

Section 1

Section 2

Section 3