Bar Land Coverage Change Form

Bare Land Coverage Change

Housing Authority or Insured Entity*
Insured's address*
Street Address Address Line 2 City State ZIP Code
Your name*
First Last
Your email*
Phone*
Location Information
Location name*
Tax ID
Location address*
Street Address Address Line 2 City State ZIP Code
Effective date*
MM slash DD slash YYYY
Do you plan to develop the bare land?*
- YES
- NO
If YES,
Provide a brief narrative of timeline and who will own the land before, during, and after construction?
Are there any outbuildings on the property?*
- YES
- NO
Are there “No Trespassing” signs clearly posted?*
- YES
- NO
ELECTRONIC SIGNATURE*
- I certify that the information on the application is true and accurate to the best of my knowledge. I understand that if alternate information becomes available, it may result in a change of premium or policy/coverage cancellation. By submitting I am providing my electronic signature.
Name
This field is for validation purposes and should be left unchanged.

(360) 574-9035 x107

(360) 574-9035 x104