Tunit-Ca - Unit Renters Insurance Form

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Unit Renters Insurance
Agent/Broker Name Address
Proposed Effective Date:
At 12:01 AM Standard Time
Occupancy: Renter
Units in Building:
Stories in Building:
Complete address of Property to be Insured
[ ] Same as Mailing Address
Applicants Full name (must be legal Owner)
Address
City
State
Zip Code
Mailing Address
Year Built:
Roof Material:
No. of Families:
City
State
Zip Code
Construction Type: [ ] Wood Frame [ ] Masonry
No. Square Feet:
Home Phone Number
Work Phone Number
Feet to Fire Hydrant:
Miles to Fire Station:
Debits, Credits and Other Coverages
Premium
I. Workers Compensation (
)
California only
# in servants:
# out servants:
$
Coverages
Limits
Premium
J. Higher Deductible ($500 basic) [ ] $1,000
$
C. Personal Property:
$25,000 min. $50,000 max.
$
$
K. Protection Class 9-10 Surcharge (Class #: )
$
D. Loss of Use
10% of C
Included
L. Theft Coverage - $3,000 limit included
$Included
E. Personal Liability Limit:
M. [ ] Burglary Alarm Credit [ ] Fire Alarm Credit
$50,000 or $100,000
[ ] Both
$
$
$
N. Annual Premium (Minimum $150)
$
F. Earthquake – disclosure required
O. Policy Fee $40 Inspection Fee $25 – Fully Earned
(
)
$
$
$65.00
California only
G. Water Damage Limit:
$5000 or $10,000
$
$
Total Amount Due
$
H. Replacement Cost Personal Prop.
Same as C
$
First Mortgagee Name & Address – cannot be an individual or
Second Mortgagee Name & Address – cannot be an individual or
Trustee
Trustee
Loan Number
Loan Number
Prior Insurance Carrier, either at this location or any previous location: _______________________________________________
Their Policy number_____________________________ Why did you change Carriers? _________________________________________
Loss History: Have there been ANY property or personal liability claims in the past 36 months? [ ] NO [ ] YES
Date of Loss
Insurance Company Description of Loss
Amount of Loss
Is there any un-repaired damage from any of these losses? [ ] NO [ ] YES – risk unacceptable.
COMPLETE THE REVERSE SIDE OF THIS APPLICATION
TUNIT-CA (2/11)

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