Vacant Dwelling/
 Vacant Building/
Vacant Mobile Home
I N S U R A N C E   I N Q U I R Y
(Pennsylvania properties only)

Name:
Mailing Address:
City:
      State:     Zipcode: 
Phone Number:
Fax Number:
E-Mail Address:

                                                  Applicant is a            Requested Effective Date of Coverage: 
 

Vacant Dwelling/Building/Mobile Home Location Information:

Location Address:
City:
   State:   Zipcode: 

Coverage Limits
WHAT WE ARE INSURING:
WHAT VALUATION ARE YOU USING?
Building Insured Value
Actual Cash Value (what its worth) /  Replacement Cost (cost to rebuild new)
Outbuildings or other detached buildings:
Personal Property / Contents:
 
MOBILE HOMES ONLY
Tied Down:  Yes /  No                    Skirted:  Yes /  No
 


Building Information
Type of Dwelling:        Year Built: 

Number of families or units: 

How Long Owned: 
If less than 1 year....Purchase Price $ 
Square Footage of Dwelling:     # of Stories: 

Construction: 

Number of Acres:          

Is there a pool, pond or lake on the property?  Yes /  No

Describe General Condition of Building:  Very Good         Good         Fair         Poor
Why is it Vacant?           Since (Month/Year): 
Prior Occupancy (What was in their before it was vacant): 
Future Plans for the property: 
Is the property currently under renovation or are there plans for renovation? Yes / No
Description of work to be done:
Date work started or will start:
Cost of Renovation:
Work to be done by:
Insured /  Contractor
Are regular checks on building?
Yes / No
Is the building secured or alarmed?
Yes / No
Describe the neighborhood: 
Is the interior of the building free of garbage, debris, refuse, etc?  Yes / No


General Questions
Is the property current insured?    If yes, with what insurance company? 
Yes /  No
Have there been any losses or incidents at this property in the last three (3) years?
Yes /  No
Is there any un-repaired damage from a previous loss?
Yes /  No
Have you filed for bankruptcy in the last five (5) years?
Yes /  No
As the owner of the property, have you evicted the prior occupants or foreclosed on lease purchases in the past 12 months?
Yes /  No
Is the property currently 100% vacant (except for renovations)?
Yes /  No


Mortgagee or Loss Payee Information
Name:
Address:
City:
   State:   Zipcode: 



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M c G R A T H   I N S U R A N C E   G R O U P

4170 William Penn Highway, Murrysville, PA. 15668-1890
(724) 327-8474           (fax) 327-7911
Toll Free: 1-800-977-2999      Fax: 1-888-800-0034