Commercial General Liability

Tenant Occupied Three-Family Dwelling Submission Form

Applicant Information:

Classification Code: 63012 Tenant Occupied 3-Family Dwelling (LRO)

Occupancy Type:

More than 20% Subsidized, HUD or Section 8? (if yes, please submit)

More than 25% student occupancy? (if yes, please submit)

'Mobile Home' rented to others? (if yes, please submit)

Working smoke detectors in all units?

Are there are burglar bars? If Yes, are they equipped with functional quick release mechanism and emergency access hardware?

Vacation rental, AirBNB, Hotel, Motel, Single Room occupancy? (if yes, please submit)

Treatment or Recovery Facility, Assisted Living, Senior Living? (if yes, please submit)

Security guards?

Any swimming pool, spa, hot tub, portable spa or non-portable pool? (if yes, please submit)

Loss History

As a condition precedent to coverage, I hereby state that the information contained herein is true, accurate and complete and that no material facts have been omitted, misrepresented or misstated. I know of no other claims or lawsuits against the applicant and I know of no other events, incidents or occurrences which might reasonably lead to a claim or lawsuit against the applicant. I understand that this is an application for insurance only and that completion and submission of this form does not bind coverage with any insurer.