vacant prop rou091 201104
8417 Patterson Avenue Richmond, Virginia 23229 Telephone: (804) 741-7999 WATTS: (800) 628-2967 Fax: (804) 741-9401 www.royaloakunderwriters.com
ROYAL OAK UNDERWRITERS, INC. Excess and Surplus Lines Insurance Wholesalers
APPLICATION FOR VACANT PROPERTY PROGRAM APPLICANT NAME Mailing Address: City:
State Zip
Telephone Number: Policy Term: Location Property Limit Requested: Building $ Perils Requested:
Fire
E.C.
(80% Coins)Deductible $ Vandalism Other
General Liability Limits Requested $ How long has applicant owned property at this location?
How long has building been vacant?
Prior Occupancy Year Built No. of Stories
Year Renovated
Year Systems Upgraded
Construction
Year Roof Replaced
Intended Disposition of Property (i.e., sell, rent, occupy) Describe neighborhood - i.e., rural, commercial, residential Describe general condition of building Describe unrepaired damage, if any How often are regular checks made to premises? Is building clear/secured/alarmed?
Photos attached?
Yes
No
Utilities operational?
Loss History Bankruptcy Status:
Mortgagee
Previous Carrier Other pertinent information
Producer Name
Applicant Signature
Signature
Date
Address Reset Form rou091-201104
Submit by E-mail Page 1 of 1
Print Form
SAVE
Royal Oak Underwriters, Inc.
ROYAL OAK UNDERWRITERS, INC. Excess and Surplus Lines Insurance Wholesalers
APPLICATION FOR VACANT PROPERTY PROGRAM APPLICANT NAME Mailing Address: City:
State Zip
Telephone Number: Policy Term: Location Property Limit Requested: Building $ Perils Requested:
Fire
E.C.
(80% Coins)Deductible $ Vandalism Other
General Liability Limits Requested $ How long has applicant owned property at this location?
How long has building been vacant?
Prior Occupancy Year Built No. of Stories
Year Renovated
Year Systems Upgraded
Construction
Year Roof Replaced
Intended Disposition of Property (i.e., sell, rent, occupy) Describe neighborhood - i.e., rural, commercial, residential Describe general condition of building Describe unrepaired damage, if any How often are regular checks made to premises? Is building clear/secured/alarmed?
Photos attached?
Yes
No
Utilities operational?
Loss History Bankruptcy Status:
Mortgagee
Previous Carrier Other pertinent information
Producer Name
Applicant Signature
Signature
Date
Address Reset Form rou091-201104
Submit by E-mail Page 1 of 1
Print Form
SAVE
Royal Oak Underwriters, Inc.
