SureVestor ProtectionPlus Bundle Application

Property Management Information

Contact Name(Required)

First Last

Email(Required)

Title(Required)

Phone(Required)

Property Management Company Name(Required)

DBA if Any

Website(Required)

Entity Type(Required)

Physical Address(Required)

Street Address City State ZIP Code

Acknowledgement(Required)

This product is only for professionally managed residential properties

Portfolio Overview

1. Long Term Rentals in your Portfolio (> 6 Months)(Required)

2. Long Term Rental % of your Portfolio (>6 Months)(Required)

3. Long Term Rental % of your Portfolio (<6 Months)(Required)

4. Flip/Renovate and Sell % (<6 Months)(Required)

5. Buy/Hold Investment % (>6 Months)(Required)

6. Other (Please Describe)

Number of Units 1-4:(Required)

Number of Units 15-20(Required)

Number of Units 21+(Required)

*NOTE: Locations with 21+ units in a building are not permitted at this time for general liability.

Product Bundle Selection

Select the appropriate product bundle below:(Required)

Landlord Protection, General Liability & Tenant Legal Liability

Landlord Protection & General Liability

Tenant Legal Liability (TLI $100,000 in Liability Coverage)

Would you like to add $100,000 of contents coverage for tenant?(Required)

Yes

No

*Note: Subject to terms and conditions of the policy & $4 additional per month

Loss History

1. Have you been enrolled in a TLI, TLL, or RLL program before?(Required)

Yes

No

2. Number of Renter Liability losses in the past three years?(Required)

Type of Losses

4. Has Coverage been cancelled or non-renewed?(Required)

Yes

No

Loss History

1. Has the insured had their insurance coverage cancelled?(Required)

Yes

No

1a. For what reason was the coverage cancelled?

No Payment

Claims/Losses

Other

2. Have you had any General Liability claims in the past 3 years?(Required)

Yes

No

2a. When did you have General Liability claims, what were the details on loss, and what was the claim total?

Landlord Protection (LP)

Acknowledgment(Required)

You understand that if a tenant has not made payment on time (by the 5th of the month) and is behind on payment coverage for Loss of Rent, Malicious Damage, and Eviction cost will not be covered until the tenant is up to date and paid 2 consecutive months on time (by the 5th of the month).

You will not add locations to this policy where you are aware of a situation that could lead to a claim.

You understand that this product must have a monthly rent amount of $1,000 or more. You also understand the maximum rental limit is $3,000 which means you can add locations with higher rent values but the coverage will cap at $3,000.

You acknowledge that as a professional property management company you will continue to use best practices in screening and placing of tenants. This insurance does not replace your duty of care for screening tenants.

There are no known losses or claims that have not already been reported to a prior insurance carrier, or to any other source from which claims might be made; There is no knowledge of facts or circumstances that relate to an occurrence, wrongful act, or incident of any type, including those caused by incremental, continuous, or progressive damage; arising from any of the insured’s operations, employees, or affiliates acting on the insured’s behalf which could reasonably result in a claim, that have not been reported to a prior insurance carrier; There is no knowledge of any requests for information by anyone, including an attorney, which might result in a claim; and There is no knowledge of any prior insurance carrier refusing coverage for, or declining to accept a report of any occurrence, incident, threat of claim, letter of intent, adverse result notice, or attorney contact.

Signature

Date

Initial the following, indicating you have had the opportunity to review:

1. Initial(Required)

I warrant that the information contained in this application is true, it becomes part of my insurance application, and is subject to the same warranties and conditions. This statement will form the basis of and be incorporated into the final policy, if issued.

By initialing here, you are hereby agree to the following State Specific Guidelines.

2. Initial(Required)

I understand that this quote and policy if offered is offered by a non-admitted or surplus lines insurer rated currently rated A XV by A.M. Best.

By initialing here, you are hereby agree to the following State Specific Guidelines.

3. Initial(Required)

I understand that by purchasing this insurance I am joining the Professional Industry Purchasing Group, an approved Risk Purchasing Group (RPG), and understand the terms and conditions of the Membership Agreement.

By initialing here, you are hereby agree to the following RPG Agreement.

4. Initial(Required)

I agree to and understand the terms and conditions of the policy(s).

An example policy for your reference can be found here.

FRAUD STATEMENT

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND CIVIL PENALTIES.

I warrant that the information contained in this application is true, it becomes part of my insurance application, and is subject to the same warranties and conditions. This statement will form the basis of and be incorporated into the final policy, if issued.

THE UNDERSIGNED EXECUTIVE OFFICER, DIRECTOR, PARTNER, OR EQUIVALENT insured OR AUTHORIZED REPRESENTATIVE DECLARES THAT THE STATEMENTS SET FORTH HEREIN ARE TRUE. THE UNDERSIGNED AGREES THAT IF THE INFORMATION SUPPLIED ON THE APPLICATION CHANGES BETWEEN THE DATE OF THE APPLICATION AND THE EFFECTIVE DATE OF THE INSURANCE, HE/SHE (UNDERSIGNED) WILL IMMEDIATELY NOTIFY THE INSURER OF SUCH CHANGES, AND THE INSURER MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS AND/OR AUTHORIZATION OR AGREEMENT TO BIND THE INSURANCE. SIGNING OF THIS APPLICATION DOES NOT BIND THE insured TO THE INSURER TO COMPLETE THE INSURANCE.

THE insured AGREES TO NOTIFY US OF ANY MATERIAL CHANGES IN THE ANSWERS TO THE QUESTIONS ON THIS QUESTIONNAIRE WHICH MAY ARISE PRIOR TO THE EFFECTIVE DATE OF ANY POLICY ISSUED PURSUANT TO THIS QUESTIONNAIRE AND THE insured UNDERSTANDS THAT ANY OUTSTANDING QUOTATIONS MAY BE MODIFIED OR WITHDRAWN BASED UPON SUCH CHANGES AT OUR SOLE DISCRETION. COMPLETION OF THIS FORM DOES NOT BIND COVERAGE. insured's ACCEPTANCE OF THE COMPANY'S QUOTATIONS IS REQUIRED PRIOR TO BINDING COVERAGE AND POLICY ISSUANCE. ALL WRITTEN STATEMENTS AND MATERIALS FURNISHED TO THE COMPANY IN CONJUNCTION WITH THIS APPLICATION ARE HEREBY INCORPORATED BY REFERENCE INTO THIS APPLICATION AND MADE A PART OF THIS APPLICATION.

Signature(Required)

Date(Required)

SureVestor Protection Plus Application

Property Management Information

Operational Overview

Portfolio Overview

Product Bundle Selection

Tenant Legal Liability (TLI $100,000 in Liability Coverage)

Loss History

General Liability (GL)

Loss History

Landlord Protection (LP)

Initial the following, indicating you have had the opportunity to review:

FRAUD STATEMENT

Introducing the ProtectionPlus Bundle.

SureVestor Protection Plus Application

Property Management Information

Operational Overview

Portfolio Overview

Product Bundle Selection

Tenant Legal Liability (TLI $100,000 in Liability Coverage)

Loss History

General Liability (GL)

Loss History

Landlord Protection (LP)

Initial the following, indicating you have had the opportunity to review:

FRAUD STATEMENT