Personal Lines Multiple Dwelling Product Supplemental Application ...

CARRIER:

Personal Lines Multiple Dwelling Product Supplemental Application – All States Location # _________________________________________________ Address: _______________________________________________ # of Units _______________________________________________ Year Built: ____________________

Square Footage: __________________________

Protection Class: _______________

Construction Type:

Roof Type:

Roof Age:

Occupancy:

Coverage “A”: $

Protective Devices:

 Frame

 Flat

___________

 Owner

_____________

 Fire Extinguishers

 Joisted Masonry

 Asphalt Shingle

 Masonry Veneer

 Wood Shake

 Log Home

 Tile

 Row House or

 Metal

Town House

 Smoke Detectors

 Tenant HVAC Age: ___________

 Vacant  Seasonal/Timeshare

Coverage “C”: $ _____________

 Central Fire  Central Burglar  Deadbolt locks

 Slate

Location # _________________________________________________ Address: _________________________________________________# of Units _______________________________________________ Year Built: ____________________

Square Footage: __________________________

Protection Class: _______________

Construction Type:

Roof Type:

Roof Age:

Occupancy:

Coverage “A”: $

Protective Devices:

 Frame

 Flat

___________

 Owner

_____________

 Fire Extinguishers

 Joisted Masonry

 Asphalt Shingle

 Masonry Veneer

 Wood Shake

 Log Home

 Tile

 Row House or

 Metal

Town House

 Smoke Detectors

 Tenant HVAC Age: ___________

 Vacant  Seasonal/Timeshare

Coverage “C”: $ _____________

 Central Fire  Central Burglar  Deadbolt locks

 Slate

Location # _________________________________________________ Address: _________________________________________________# of Units _______________________________________________ Year Built: ____________________

Square Footage: __________________________

Protection Class: _______________

Construction Type:

Roof Type:

Roof Age:

Occupancy:

Coverage “A”: $

Protective Devices:

 Frame

 Flat

___________

 Owner

_____________

 Fire Extinguishers

 Joisted Masonry

 Asphalt Shingle

 Masonry Veneer

 Wood Shake

 Log Home

 Tile

 Row House or

 Metal

Town House

 Smoke Detectors

 Tenant HVAC Age: ___________

 Vacant  Seasonal/Timeshare

Coverage “C”: $ _____________

 Central Fire  Central Burglar  Deadbolt locks

 Slate

Location # _________________________________________________ Address: _________________________________________________# of Units _______________________________________________ Year Built: ____________________

Square Footage: __________________________

Protection Class: _______________

Construction Type:

Roof Type:

Roof Age:

Occupancy:

Coverage “A”: $

Protective Devices:

 Frame

 Flat

___________

 Owner

_____________

 Fire Extinguishers

 Joisted Masonry

 Asphalt Shingle

 Masonry Veneer

 Wood Shake

 Log Home

 Tile

 Row House or

 Metal

Town House Supplemental DWGA 10/14 – USLI

 Smoke Detectors

 Tenant HVAC Age: ___________

 Vacant  Seasonal/Timeshare

Coverage “C”: $ _____________

 Central Fire  Central Burglar  Deadbolt locks

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