Underwriter:Broker:Date:

EARTHQUAKE APPLICATION

This application forms and becomes part of your insurance policy

I N S U R E D / Named Insured: Effective Date:
DBA:
Mailing Address:
Location Address: Entity: LessorTenantOwner Occupant

Coverage must be 100% replacement cost

/ Deduc

Building: $

Contents: $
Business Income/EE: $
APC: $ Pools Fences Paved Surfaces
Coverage for Business Income/Extra Expense and Additional Property Coverage is provided on a per location basis. / Earthquake Sprinkler Leakage: Yes No
Ordinance or Law:
None 10% 20%
Tenants Improvements:
$ / Mold Clean-Up
And Removal Coverage:
$10,000 (bldg only)
25% All Cov.
50% All Cov / 2%
5%
7.5%
10%
15%
20%

NOTICE TO PRODUCER/INSURED:

Any person who knowingly and with intent to defraud an insurance company or other person, files an application for insurance containing false information or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act which is a crime.

  1. Year Built:
  2. Total # of Stories:
  3. TotalBuilding Area:
  4. Total # of Buildings:
  5. Occupancy:
  6. Agri-Business
  7. Apartment
  8. Condo Association
  9. Hotel/Motel
  10. Manufacturing
  11. Office
  12. PublicBuilding
  13. Restaurant
  14. Retail
  15. School
  16. Service
  17. Warehouse
  18. Wholesale
  19. Construction Class:
  20. Brick Veneer
  21. Fire Resistive
  22. Joisted Masonry–Reinforced Masonry
  23. Joisted Masonry–Tilt Up
  24. Joisted Masonry–Un-Reinforced Masonry
  25. Masonry Non-Combustible
  26. Modified Fire Resistive
  27. Non-Combustible
  28. Wood Frame
  1. Parking Class:
  2. Attached – No structure above
  3. Detached
  4. First Floor Parking
  5. Full Subterranean
  6. Habitational Over Garage (HOG)
  7. Partial Subterranean
  8. Soft First Floor
  9. Tuck Under – 1 side
  10. Tuck Under – 2 sides
  11. None
  12. If building was built prior to 1940, when was/were the building(s) updated?
  13. Is/are the building(s) bolted to the foundation?

(wood frame or modular only)

Yes No

  1. Does risk have flood coverage?

Yes No

PERSON TO CONTACT FOR INSPECTION:

TELEPHONE #:

PRODUCER

SIGNATURE:

DATE:

NOTICE TO PRODUCER/INSURED:

Any person who knowingly and with intent to defraud an insurance company or other person, files an application for insurance containing false information or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act which is a crime.

If more than one building OR location, please complete the following as part of the application

If building is wood frame, please advise whether the building is bolted to the foundation

Loc # / Bldg # / Street, City, State, Zip / Building Value / Contents Value / T.I.B / Business Income / Year Built / Construction Type / Area/
Sq Ft / # of
Story / Type of Parking / Occupancy

CONSTRUCTION SYMBOLS:

BV: BRICK VENEERFR: FIRE RESISTIVEJMR: JOISTED MASONRY-REINFORCED MASONRYJMT: JOISTED MASONRY-TILT UPM: MODULAR

WF: WOOD FRAMENC: NON-COMBUSTIBLE JMU: JOISTED MASONRY-UNREINFORCED MASONRYMCN: MASONRY NON-COMBUSTIBLE

What is the building shape?Does the building have setbacks and/or overhangs?These characteristics impact the performance of buildings

Regular (square, rectangular, circular) Yesin seismic events and are a part of our rating system. They

Irregular (all other buildings shapes) Nowill be verified at inspection and may be endorsed to reflect

Unknown Unknownreflect the correct building attributes. Additional eligibility

changes will apply based on soil type, liquefaction, territory,

construction type, age, and parking type.

NOTICE TO PRODUCER/INSURED:

Any person who knowingly and with intent to defraud an insurance company or other person, files an application for insurance containing false information or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act which is a crime.