(Complete in addition to ACORD application)

Insured:      

Location:      

How long has applicant owned property at this location?      

How long has building been vacant?      

Prior Occupancy:      

Number of stories:       Year systems updated:        
Year roof replaced:      

Intended Disposition of Property (i.e., sell, rent, occupy):      

Is Building to be renovated?  Yes   No      If so, when?      

Describe general condition of building:      

Describe neighborhood (i.e., rural, commercial, residential):      

Describe unrepaired damage, if any:      

How often are regular checks made of premises?         By whom?      

Is building clear/secured/alarmed?          Utilities operational?  Yes   No

Are doors, windows, openings boarded or otherwise secured?  Yes   No

Has building been foreclosed?  Yes   No   Bankruptcy history?      

Number of mortgages:      

SIGNATURES ARE REQUIRED. SIGN AT THE END OF THE FRAUD NOTICES SECTION.	

	
FRAUD NOTICES:
PRIOR TO SIGNING THIS APPLICATION, PLEASE REVIEW THE FOLLOWING STATUTORY FRAUD NOTICES AS THEY MAY APPLY TO THE APPLICANT'S DOMICILE.	
Applicable in AL, AR, DC, LA, MD, NM, RI and WV
Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully)* presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. *Applies in MD Only.	
Applicable in CO
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.	
	
Applicable in FL 
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony (of the third degree). 	
Applicable in KS
Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act. 	
Applicable in KY, NY, OH and PA
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 such person to criminal and civil penalties* (not to exceed five thousand dollars and the stated value of the claim for each such violation)*. *Applies in NY Only.	
Applicable in ME, TN, VA and WA
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties (may)* include imprisonment, fines and denial of insurance benefits. *Applies in ME Only.	
Applicable in NJ
Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.	
Applicable in OK 
WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony (of the third degree).	
Applicable in OR
Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law.	
Applicable in Other States:
WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of insurance fraud, which is a crime, and may be subject to fines and confinement in prison.	
THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND CERTIFIES THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO THE QUESTIONS ON THIS APPLICATION. HE/SHE CERTIFIES THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE. HE/SHE CERTIFIES THAT THE APPLICABLE FRAUD NOTICES HEREIN HAVE BEEN READ AND UNDERSTOOD.	
Applicant Name (Name of Company)	Producer’s Name	
Signature of Authorized Representative	Producer's Signature 	
Print Name	Producer’s Phone 	
Title 	Producer’s Fax 	
Date	Producer’s Email