VACANT
					PROPERTY
	Insureds Name:
	DBA Name:
	Mailing Address:
	State:		Select Maryland Pennsylvania Delaware New Jersey Virginia Washington DC
	Property Schedule
	Building #1:
	Address:
	Commercial or Residential:
	Year built:						Year
	In the past 10 years:						Updated
	Wiring updated:			Select Yes No
	Roofing updated:			Select Yes No
	Plumbing updated:			Select Yes No
	Heating updated:			Select Yes No
	Burglar or Fire alarm:			Select None Burglar Alarm Fire Alarm Both Burglar & Fire Alarm
	Construction:			Select Frame Masonry Joist Noncombustible Masonry Noncombustible Fire Resistive
	Number of stories:			Select One Two Three Four Five Other
	Protection class:			Select 1 2 3 4 5 6 7 8 9 10
	Building coverage limit:
	Contents coverage limit:
	Loss of rents limt:
	Loss of earnings limit:
	Other coverage & limit:
	Total square footage:
	Building #2 (if applicable)
	Address:
	Commercial or Residential:
	Year built:						Year
	In the past 10 years:						Updated
	Wiring updated:			Select Yes No
	Roofing updated:			Select Yes No
	Plumbing updated:			Select Yes No
	Heating updated:			Select Yes No
	Burglar or Fire alarm:			Select None Burglar Alarm Fire Alarm Both Burglar & Fire Alarm
	Construction:			Select Frame Masonry Joist Noncombustible Masonry Noncombustible Fire Resistive
	Number of stories:			Select One Two Three Four Five Other
	Protection class:			Select 1 2 3 4 5 6 7 8 9 10
	Building coverage limit:
	Contents coverage limit:
	Loss of rents limt:
	Loss of earnings limit:
	Other coverage & limit:
	Total square footage:
	How long has property been vacant:
	Future plans for property:
	Is the property checked daily:			Select Yes No
	Are all windows boarded:			Select Yes No
	Is the water turned off:			Select Yes No
	Requested term of coverage:			Select 3 Months 6 Months Annual
	Proposed effective date:
	Deductible requested:			Select 500 1,000 2,500 5,000
	Causes of Loss:			Select Basic Broad Special without Theft Special with Theft
	Co-Insurance:			Select 80% 90% 100%
	Valuation:			Select Actual Cash Value Replacement Cost
	Any Claims past 3 Years:				Select Yes No
	If claims, please provide details:
	Prior Carrier:
	Prior Premium:
	Agency Name:
	Agency Address:
	Agency Phone:
	Agency Fax:
	Agency Contact:
	Contact E-Mail Address:
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									(Version 1)