Personal : Condo Owners

Condominium
Unit #		Name of Community
Total Number of Units		Property Manager Telephone Number
Street Address
County
City
Zip/Postal Code

Building Information
Construction Type	FrameOther than Frame
Year
On what floor is the unit located?
Residence Type	Primary ResidenceSecondary Residence
Ground Level	YesNo
Distance to Water
Condo Elevated	YesNo
Unit Square Feet

Coverage
Base for $ Contents (Policy contains 100% Coinsurance Requirement) Coverage A - Dwelling of $ To include Liability of $300,000To include Liability of $500,000

Has any insurance been declined, cancelled or non-renewed in the past 3 years?	YesNo
Have there been any losses in the past 3 years?	YesNo
if Yes, please explain
Does Applicant have any dog(s) on the premises?	YesNo
if Yes, please list type of breed
Requested Effective Date

Disclaimer: The request will not become effective until after you have been contacted by one of our agents. Check this box to confirm.

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