Earthquake Insurance

Section One – Applicant

Name*

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Email

Section Two – Building Information (if different from above)

Location #

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Construction Class (Check one)*

Year Built*

Number of Stories*

Square Footage*

Parking Class (Check one)*

Occupancy (Check one)*

Explain Occupancy Class in Detail*

Building Shape*

Regular
Irregular
Unknown

Setbacks or Overhangs*

Yes
No
Unknown

Insured's Interest*

Lessor
Tenant
Owner Occupant

Requested Coverage

Building*

(100% Replacement Cost Required)

BPP*

(100% Replacement Cost Required)

Tenant Improvements and Betterments

Inspection Contact Name*

Inspevtion Phone*

Requested Effective Date*

Deductible Option (Check one)*

Mold Clean-Up and Removal Coverage*

$10,000 (Building only)

No
Yes

Earthquake Sprinkler Leakage (Check one)*

No
Yes

Flood Coverage (Check one)*

No
Yes

Ordinance or Law (Check one)*

None
10% Sublimit
20% Sublimit

Business Income Coverage (provided on a <em>per location</em> basis)

BI/EE (for loaction)

Additional Property Coverage (provided on a <em>per location</em> basis)*

APC (for location)

Please select which APC's are application for this location*

Pools
Fences
Paved Surfaces

Section One – Applicant

Section Two – Building Information (if different from above)

Requested Coverage

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