Firstname *		Lastname *		The first step toward correctly insuring your Co-op begins with a review of your Co-op incorporation papers. Be sure you receive a copy of the document before purchasing the Co-op. What property is your responsibility to insure? From inside the walls? The internal walls? The appliances? Your separate and detached garage? What is the potential for loss assessment after a fire? Does the association or corporation insure the buildings owned by the association to replacement value? How high is the association's deductible? What is not insured? Are there any coverage's, limits or additional interest endorsements you must add to your policy as required by the association agreement or incorporation document?
Policyholder Name
Occupation
Current Employer
Street Address
City *		State * AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDist of ColumbiaDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming		ZIP Code *
E-Mail *
Phone *				Fax
Currently Insured * YesNo				Mortgage Closing * YesNo
Wood-Burning Stoves * YesNo				Dead Bolt Locks * YesNo
Fire Extinguishers * YesNo				Smoke Detectors * YesNo
Smoke-free Household * YesNo				Neighborhood Watch Program * YesNo
Sprinkler System * YesNo				Gated Community * YesNo
Garage * YesNo