Landlord Insurance Application for Rental Home

Desired Effective Date*

General Information

Insured Name*

Insured Contact

Mailing Address

Street Address*

Building / Suite Number

City*

State*

Zip Code*

Phone Number*

Email*

Preferred Method of Contact*

Property Information

Property Address

Street Address*

Building / Suite Number

City*

State*

Zip Code*

County*

Type of property:*

Residential Commercial

How many units are in the building?*

Is the building 100% tenant occupied?*

Yes No

Are all tenants required to sign an annual lease?*

Yes No

Is any farming or other business conducted on premises (including day/child care)?*

Yes No

Is the building rented to students or a fraternity or a sorority?*

Yes No

Is any unit subsidized by the government?*

Yes No

Have there been any losses on the property in the last 3 years?*

Yes No

Please provide the date, description, and dollar amount of each loss.*

Are there any nuisance hazards on the property?*

Yes No

Is the lot size more than 5 acres?*

Yes No

Have you had a foreclosure, repossession or bankruptcy in the past 5 years?*

Yes No

During the past 5 years, have you been indicted for or convicted of any degree of the crime of fraud, bribery, arson or any other arson-related crime?*

Yes No

Is the building listed on a historical register?*

Yes No

Describe the neighborhood*

Excellent Very Good Good Fair Poor

Describe the building condition*

Excellent Very Good Good Fair Poor

How often is the building checked on and by whom?*

Is there a kitchen and bathroom in all units?*

Yes No

Is a wood stove, space heater or temporary heating unit used in any of the units?*

Yes No

Does the building have working smoke detectors in all units?*

Yes No

Is there a pond, lake, pool or hot tub on premises?*

Yes No

Are any exotic animals (snake, monkey, etc.) kept on the premises?*

Yes No

Are any dogs on the premises?*

Yes No

Any Dobermans, Chows, Rotweilers, Pit Bulls, Akitas, Great Danes, Wolves or Wolf Hybrids or any mix of these breeds?*

Yes No

Any dogs with a previous bite history?*

Yes No

Is the building equipped with functioning circuit breakers?*

Yes No

Date purchased*

Purchase price*

Date rented*

Please provide the current insurance carrier name, policy number, and effective dates. If you have not had continuous coverage in place since the property was purchased, this risk is not eligible under our Rental Home program.*

Is there an Additional Interest that needs to be listed?*

Yes No

Please select the interest type.* Loss Payee Mortgagee

Please provide the name, mailing address, and loan number if applicable.*

Coverage Information

Current Actual Cash Value of existing building or structure, excluding land*

Would you like to include Loss of Rents coverage?*

Yes No

Monthly Rental Value*

Would you like to include Premises Liability coverage?*

Yes No

Desired limit of liability* $100,000 $300,000 $500,000 $1,000,000

Submit Application

About Us | Apply for Insurance | Request a Call | Pay My Bill | File a Claim

About Us | Apply for Insurance
Request a Call | Pay My Bill
| File a Claim

(800) 431 - 4836 | info@insurancelinkdirect.com | Hours: 8:00 a.m. - 6:00 p.m. ET | P.O. Box 10197, Jacksonville, FL 32247