Vacant Land

Insurance Agency		AGENT INFO
Your Name
Your Email Address
Your Phone Number
California, Nevada or Hawaii License Number enter “broker” if you already have a broker agreement with us

Name of Insured		INSURED INFO
Address of Insured
Address or Cross Street Location of Vacant Land AND Area of Vacant Land in Acres or Square Feet
#1 Location:	Area:
#2 Location:	Area:
#3 Location:	Area:
#4 Location:	Area:
#5 Location:	Area:
#6 Location:	Area:
#7 Location:	Area:
#8 Location:	Area:
#9 Location:	Area:
List Additional Insureds and Their Insurable Interest if none, enter “none”
NOTE: All Fields Must Be Completed