Brick & Brownstone Insurance Program Application:

Note: If incomplete application information is submitted, we may not be able to provide an indication or quote.

Agency/Brokerage Name:	(Cannot contain: \ / : * ? " < > \|)
Agency/Brokerage Address1:
Agency/Brokerage Address2:
Agency/Brokerage City:
Agency/Brokerage State / Zip:
Contact Name:
Phone Number:
Fax Number:
Email Address:
Email Address Confirmation:
1. Named Insured:
Mailing Address Line 1:
Mailing Address Line 2:
Mailing City:
Mailing State / Zip:
2. Building Address:
Building City:
Building State:
Building Zip:
Requested Effective Date:

3. Loss History:/B>
Have there been any GL/ Property claims in the last four years?
Has there ever been a lead or mold complaint, claim or lawsuit?
Has this building ever been tested for lead based paint?
We will provide a quote, subject to receipt of hard copy carrier loss runs, prior to binding. If yes, please list any claims for the past 4 years.

Date of Loss:	Incurred Amount:	Status:	Details:

4. Additional Interests:

Mortgagee Name:

Mortgagee Address:

Mortgagee City:

Mortgagee State/ Zip:

Bill Bank for Premium?

Loan Number:

5. Ownership:
# of Habitational Units:
# of Stories:
# of Buildings:
Owner Occupied?
Building Type:
If "Other" describe:If "Other" describe:

6. Building Information:
Year Built:
Construction Type:
Percentage Occupied:
# of Elevators:
Total Bldg Sq. Feet:
7. Renovation Updates:	Year of Renovation:
Gut Rehab:
Roof:
HVAC:
Plumbing:
Electrical:
Electrical Wiring Protection:
If fuses, what type?
8. Property Section (Requested Coverage):
Building Limit:
Loss of Rents:
Co-Insurance:
Causes of Loss:
Valuation:
Deductible:
Building Ordinance:
Backup sewers and drains:*
Flood:*
Earthquake:*
* Higher/Lower Limits Available
8a. Property: Requested Coverage (Owner Occupied Only):
Personal Property:
Crime Limit:
Additional Living Expenses:
* Higher/Lower Limits Available
9. Liability: (Requested Coverage):
Comprehensive General Liability:
Comprehensive Personal Liability: (Owner Occupied Only):
Non-Owned & Hired Auto Liability:
Water Damage Legal Liability:*
Fidelity:

* Higher/Lower Limits Available

10. Life Safety::
Building Code Violations:
Sprinkler System:
Smoke Detectors:
Garages:	Sq. Ft.

11. Do buildings contain the following?
Mercs Present?	How many?
Rented Offices?
Retail Stores?
Restaurants?
Day Care?
Commercial Sq. Ft.

12. Please enter value of requested limit (Owner Occupied Only - Attach Apprasial or Bill of Sale):

Jewelry:
Furs:
Fine Arts:
Silver:
Bicycles:
Golf:
Books:
Cameras:
Musical:
Antiques:

13. Umbrella Limit Options:

(Umbrella available only when GL and Property policies are purchased).

14. Current or Prior Carrier Information:
Carrier:
Policy Number:
Expiration Date:
Limits:	Building: Liability: Other:
Annual Premium:
Any policy cancellations or non-renewals during the past 3 years?
If yes, describe:

15. Inspection Contact:
Contact Name:
Phone Number:

THE FOLLOWING RISKS ARE INELIGIBLE FOR THE NEW YORK BRICK & BROWNSTONE PROGRAM: HOMELESS SHELTERS; SHELTERS; EMERGENCY SHELTERS; SUBSTANCE ABUSE PROGRAMS; MENTAL HEALTH FACILITIES; SROs (SINGLE ROOM OCCUPANCY); FRATERNITY OR STUDENT HOUSING; ANY NON-PROFIT CITY OR STATE SPONSORED SOCIAL SERVICE ENTITY, AGENCY, OR AFFILIATION; ANY UNCORRECTED TYPE 'B' OR 'C' BUILDING VIOLATIONS IN THE PRIOR THREE (3) YEARS.

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON WHO 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 SUBSTANTIAL CIVIL PENALTIES AND INSURANCE BENEFITS MAY ALSO BE DENIED.

Email Address:

By clicking "Submit Application" below, you are agreeing to the foregoing statement that the above email address is your correct address that you have completed this application and that you are signing this application.