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Vacant Homes and Tenant Occupied Properties Application Form

Please fill out the application form below and click the Submit button to obtain a quote from XN Financial.

Required fields are identified by an asterisk.

If the submitted form does not pass validation, a list of fields will appear with a brief explanation and the respective fields will be highlighted in red throughout the form.

 

Amounts are in USD

Client Information:
Title *:
First Name *:
Last Name *:
Email (documents will be sent to this email address) *:  
Legal Name Appearing on the Policy is same as Client Name*: Yes No

Vacant Property Address:
Address Line 1 *:  
Address Line 2 :  
City *:  
Zip / Postal Code *:  
Country *:  
State / Province / Region *:  


Mailing Address:
Same as Vacant Property Address*: Yes No

Details of Vacant Property:
Construction *:
Heating *:
Wood Stove *: Yes No
Year of Construction (yyyy) *:  

Coverage Options:
Insurance Limit Requested on Building *:
Personal Liability Amount Requested *:
Home Contents Limit *: Other
Continuing Expense Coverage *:
To pay the cost of utilities, mortgage principal, interest and taxes following a covered loss obligating you to temporarily remove this dwelling from the real estate market.
Other
Earthquake Protection *: Yes No
Flood Protection *:
Yes No
Do you live by any streams of water? *: Yes No
Effective Date of Policy
(yyyy-mm-dd)
*:
Policy Period (In Months) *: 12


Mortgage Information - First Mortgagee / Loss Payee :
Is there a mortgagee for this dewelling ? *: Yes No


Loss Details:
Have you ever been refused property insurance ? * Yes No
 
How many residential losses have you suffered in the past three (3) years? *:  
 
Please enter the details below:
Please specify the details for the last 3 losses below:
Date of Loss (yyyy-mm-dd): Final Loss Amount :
Details of Loss :

Date of Loss (yyyy-mm-dd): Final Loss Amount :
Details of Loss :

Date of Loss (yyyy-mm-dd): Final Loss Amount :
Details of Loss :

On Site Security:
Strongly recommended if house value is exceeding 200,000.
Central Station Fire Alarm *: Yes No
Central Station Burglary Alarm *: Yes No
Other, Please Specify:


Occupancy:
Type of Occupancy * : Other
Commercial or Semi Commercial *: Yes No
Secondary / Seasonal *: Yes No

Is this Location Currently...:
Under Renovations ?*: Yes No
Under Construction ?*: Yes No
Do you expect your dwelling to undergo any renovations or construction during its vacancy period? * Yes No


Public Protection:
Is your dwelling within 1,000 feet
(300 meters) of a fire hydrant? *
Yes No
Is your dwelling within 5 miles
(8 km) of a fire station? *
Yes No

Supplementary Information:
Who will be responsible for the care and maintenance of your vacant dwelling while you are away? *
Will this person maintain a regular visitation schedule to your home? * Yes No




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please contact pcservice@xn.com.
The XN Financial Underwriting department.

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