Vacant Dwelling/Building/Mobile Home Insurance Inquiry
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
BUILDINGS NOT UNDER RENOVATION
Building Insured Value:
Outbuildings:
Personal Property:
BUILDINGS UNDER RENOVATION
Building Limit (Purchase Price):
Renovations Limit:
MOBILE HOMES ONLY
Mobile Home Value:
Tied Down:  Yes /  No Skirted:  Yes /  No

Building Information
Type of Dwelling:
How Long Owned: 
If less than 1 year....
Purchase Price $ 		 Number of units: 
Year  Built:  # of Stories:  Construction: 
Square Footage of Dwelling:
 Number of Acres:  Pool, Pond or Lake?  Yes /  No
Describe General Condition of Building:
Reason Vacant:
Since (Month/Year): 
Prior Occupancy (What was in their before it was vacant):
Future Plans:
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/alarmed?
Yes / No
Describe the neighborhood:
Is the interior of the building free of garbage, debris, refuse, etc?  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