Hollingsworth Insurance Services, LLC -- Apartment Coverage Application

APARTMENT
COVERAGE
APPLICATION If you are a Producer for Hollingsworth Insurance Services, LLC and would like to submit an Apartment Coverage Application, please complete and submit this form. This information will be kept confidential and will be used for internal purposes only.

Agent Information
Agent Name:
Phone #:	Fax #:
Email Address:

Date Quote Needed

Date quote needed:
(If rush, please call after quote is submitted)

Risk Information

Name of Risk:

Client Phone Number:

Location of Risk (Address):

City: State: Zip:

Mailing Address:

City: State: Zip:

Effective Date:

Annual Rent Revenues: $

Property/Building Information

Living Square Feet:

Year Built:

Year Property Was Acquired:

Construction of Building:

% Sprinklered:

Are fire alarms hard wired in each unit?: Yes No

# of Buildings:

# of Units:

# of Stories (include parking):

Type of parking:

# of Pools:

If one or more pools:

Are the pools fenced? Yes No

Do they have a self latching gate? Yes No

Are there diving boards? Yes No

Are the pool depths clearly marked? Yes No

Year updates were made to building(s) if over 30 years old:

Plumbing: Heating/air:

Roof: Electrical:

Limits/Deductions/Miscellaneous Information

Building Limit: $

Deductible:

Hired Non Owned Auto: Yes No

Please list Property Coverage, if any is requested

Please list any losses in past three years, giving details, amounts, and dates

Inspection Contact Name:

Inspection Contact Phone:

Are there any Elderly,
Student or Subsidized housing?: Yes No If yes, please provide percentage: %

Additional Comments

Please list any additional comments or information you feel relevant to this quote

This is the application for insurance and will be signed by the risk if policy is quoted and accepted. Any person who knowingly and with intent to defraud any insurance company or another 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 the person to criminal and civil penalties, (not applicable in CO, OR) insurance benefits may also be denied.

Please click on the "Submit Application" button to send your Apartment application.
One of our representatives will respond to your submission as soon as possible.


APARTMENT COVERAGE APPLICATION	If you are a Producer for Hollingsworth Insurance Services, LLC and would like to submit an Apartment Coverage Application, please complete and submit this form. This information will be kept confidential and will be used for internal purposes only.

Date Quote Needed
Date quote needed: (If rush, please call after quote is submitted)

Risk Information
Name of Risk:
Client Phone Number:
Location of Risk (Address):
City:	State: Zip:

Mailing Address:
City:	State: Zip:

Effective Date:
Annual Rent Revenues:	$

Limits/Deductions/Miscellaneous Information
Building Limit:	$
Deductible:
Hired Non Owned Auto:	Yes No
Please list Property Coverage, if any is requested

Please list any losses in past three years, giving details, amounts, and dates

Inspection Contact Name:
Inspection Contact Phone:
Are there any Elderly, Student or Subsidized housing?:	Yes No If yes, please provide percentage: %