Vacant Land Insurance Quote Form

Page Insurance, Ltd

102 Boston Street

Guilford, CT 06437

(203) 453-5258

info@pageins.com
Section 1

General Information
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:

IndividualPartnershipCorporationOther
Limit Requested:

100/200300/600500/1,0001,000/2,000
Policy Period:

3 Months6 Months9 Months12 Months
Section 2

Eligibility
In which state is the property to be insured?

Street Address

Street Address Line 2

CityState / Province

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

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

YesNo
Has / Is the Applicant currently involved in bankruptcy proceedings?

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

YesNo
Does the land to be insured exceed 500 acres?

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

YesNo
Is the land to be insured leased to others?

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

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

Abandoned equipmentBlasting exposuresCavesEnvironment CleanupLandfillsMines below the Ground that are not sealedQuarriesRailroad OperationsUnderground fuel storage / property
Are there any activities taking place on the land to be insured, including buy not limited to: (Check all that apply)

ATVsDirt BikesSnowmobilesMountain BikingBMXSkateboardingLong BoardingRock ClimbingSwimmingHuntingFishingLoggingForestry Work
Are there any water hazards on the land to be insured? Including but not limited to lakes, rivers and reservoirs.

YesNo
Does water exceed an area greater than an acre?

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

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

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

YesNo
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
Section 3

Coverage Details
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

MonthDayYear
Date
Proposed Expiry Date

MonthDayYear
Date
Medical Payments
Is TRIPRA coverage required?

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

YesNo
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*

Agency StaffInsuredOther
Agency Staff
Should be Empty:

Section 1

Section 2

Section 3