Home

Illinois Vacant Policy Quote

Hover or Click for Help

Quote Urgency:   . Customer in Office Waiting ASAP Within 1 Hour Within 24 Hours Administration Use Only

Producer Info
Producing Agency:	Your Name:	Producer #:	Producer Phone:
Preferred Response: (Req'd) E-mail     Fax     E-mail/Fax #:		Billing Method: Agent Bill     Direct Bill - Insured
Proposed Effective Date:
Check all that apply:
Fire     General Liability		Policy term requested: 3 Months (100% earned at inception) 6 Months (50% earned at inception) 12 Months (25% earned at inception)

Applicant Info
Applicant Name	Inspection Contact Name
DBA
**Location Address**	Inspection Contact Phone
**Location City, State, Zip**	Best Contact Time
Mailing Address (if same as Location, enter "SAME")	Type of Ownership: . Individual Partnership Corporation LLC
Mailing City, State, Zip (if same as Location, enter "SAME")	Premises County

Type of Risk
Class of risk: Residential Commercial Industrial	What was the prior occupancy?

General Building Info
Number of Stories 1     2     3     4 or more What is current condition of the roof: Good   Fair   Leaking   Is there a swimming pool? Yes     No	Construction   . Frame Brick Veneer Brick/Joisted Masonry Fire Resistive Non-Combustible Other - Fill in below   Year building was built: Square Foot at Grade Level:
Is the structure sprinklered? Yes     No   If yes, is it turned on? Yes     No	Number of fire walls/fire divisions in building (if any)
Is there a working automatic fire alarm in service? Yes     No	Fire Protection Dead Bolt Locks Fire Extinguisher
How is the premises secured preventing unauthorized entry?
General Building Comments:

Vacant Risk Questions
Date property became vacant?	Date property was purchased?   If within 3 years, what was purchase price?
Is the building for sale or lease? For Sale     For Lease     Neither   If for sale, what date was property put up for sale?	Are regular security checks made? Yes     No   If yes, how frequently?
Are the utilities presently on? Yes     No	Reason building is vacant?
Expected date of occupancy?	Neighborhood type: Residential     Mfg/Industrial Retail/Commercial     Rural Other
Is the building scheduled for demolition? Yes     No	Is the building in foreclosure? Yes     No
Is there a governmental order to vacate or destroy the building; or has the building been classified as uninhabitable or structurally unsafe? Yes     No
Property Coverages	Coverage Amount	Deductible
Building 1
Building Coverage - Existing Structure (ACV)      Basic     Broad		. $500 $1,000 $2,500 $5,000
Central alarm system? Yes     No
Other Structures - Describe structure below
Description:		. $500 $1,000 $2,500 $5,000
Construction:  . Frame Brick/Joisted Masonry Fire Resistive Non-Combustible Other - Fill in below
Building Coverage      Basic     Broad
Central alarm system? Yes     No
Liability Coverages
Coverages	Coverage Amount
General Liability Coverage	. None $100,000 $300,000 $500,000 $1,000,000
Products Liability Coverage	. None $100,000 $300,000 $500,000 $1,000,000
Damages to Premises Coverage	. None $50,000 $100,000
Medical Payment	. None $1,000 $2,000 $5,000

Must be Completed - General Underwriting Questions
Have there been any PROPERTY or LIABILITY claims in the last 3 years? (Req'd)	(Type "YES" or "NO") (If yes, describe below)
Has the applicant ever been convicted of any degree of arson?	Yes   No
Does/Will the risk have any of the following:   Wood shake roof   /   Knob and tube wiring   /   Aluminum wiring   /   Fuses	Yes   No
Has the applicant had any history of bankruptcy?	Yes   No
Explain any "Yes" answers:
Comments:
All quotations are subject to satisfactory Property Inspection. (Inspection fee is fully earned at inception of policy.)
NO FLAT CANCELS WILL BE ALLOWED AFTER INCEPTION OF POLICIES.
Agent/Applicant warrants that above are true to the best of his/her knowledge.

If you wish to have a copy of this submission for your records, you must print page BEFORE submitting.

Please note - There might be a delay upon submission. Do not exit until you receive the "Confirmation Page."

powered by Spreadsheet Converter