Operator: William Warren Properties dba StorQuest
Master Policy Number: MWE 314743
Facility Name:
Applicant Name:
Space or Unit #:
IN RETURN FOR THE PAYMENT OF THE PREMIUM AND SUBJECT TO ALL THE TERMS OF THE CERTIFICATE OF INSURANCE, I WANT TO ENROLL IN THE SELF STORAGE TENANT INSURANCE PROGRAM UNDERWRITTEN BY OLD REPUBLIC INSURANCE COMPANY AND ADMINISTERED BY XERCOR INSURANCE SERVICES LLC AS FOLLOWS:
Amount of Insurance: $ Monthly Premium: $ Insurance Start Date:
The Amount of Insurance entered above is the limit, or the most we will pay, subject to a $0 deductible, for damage to your property stored in the Space or Unit # shown above that is caused by a Covered Cause of Loss as shown on your Certificate of Insurance. In addition, the following Additional Coverages and Additional Covered Causes of Loss are provided, and the most we will pay under these coverages are the limits or sublimits shown below, with more detailed descriptions shown on your Certificate of Insurance.The amounts payable under these Additional Coverages and Additional Covered Causes of Loss are part of and not in addition to the Amount of Insurance and are each subject to a $0 deductible.
Additional Coverages with limits up to the following percentages of the Amount of Insurance:
100% of the above Amount of Insurance for losses due to Burglary, Vandalism or Malicious Mischief, or property damaged while in Transit.(Transit applies only to indoor spaces or units.)
25% of the above Amount of Insurance for Debris Removal or Extra Expense for Rental Space
Additional Coverage with a sublimit up to the amount shown below:
$500 for Towing (Applies to inoperable vehicles damaged by a covered Cause of Loss)
Additional Covered Causes of Loss with sublimits up to the amounts shown below:
$2,000 for Flood
$1,000 for Rodent, Vermin, Moth, or Insect Damage
$500 for Mold, Mildew, Fungus, or Wet or Dry Rot
I acknowledge that I have elected to purchase insurance from Old Republic Insurance Company. I understand and agree that the Amount of Insurance I have selected above is the maximum limit, unless a limit providing less than 100% of the Amount of Insurance or a sublimit, as shown above, applies.Any loss paid under my Certificate of Insurance is subject to a $0 deductible. The actual amount paid in the event of loss or damage will be determined by my proof of loss documentation.
I authorize the owner, landlord, lessor, or operator of the facility (herein, the Operator) to collect my Monthly Premium and to submit it to Old Republic Insurance Company on my behalf.
My coverage will begin as of [start date] for the Amount of Insurance I have selected above, but only after I have properly completed and signed this Enrollment Form, made the first premium payment, and received a Certificate of Insurance. I understand that my insurance will continue on a month-to-month basis as long as I continue to pay the Monthly Premium shown above.My insurance will be renewed each month until I terminate the insurance or my lease or rental agreement on the storage space or unit is terminated.I understand that the Monthly Premium is due each month on or before the monthly renewal date and that the Monthly Premium is fully earned each month.
Failure to pay any premium in full each month will result in the cancellation of my insurance, without notice.
I understand that the opportunity to purchase insurance for property stored within a building or an outdoor space or unit is available to all tenants/occupants who have entered into a rental or lease agreement with the Operator for a storage space or unit. Coverage does not apply to property stored in a commercial office suite, retail space, or any other locations. Furthermore, certain types of property that I may store in an enclosed storage space or unit are excluded from coverage.It is my responsibility to read the Certificate of Insurance and understand how it may exclude coverage for some of my belongings and for some causes of loss.
I understand that I will receive 90 days of notice of changes in the premium rates, if any, and the new rate shall be payable as my Monthly Premium beginning the month after the 90 day notice period is exhausted.
I have received a Self Storage Tenant Insurance program brochure and Certificate of Insurance.I understand the manager and staff at this facility are NOT insurance agents, and that I should direct any questions regarding this insurance to Xercor Insurance Services LLC at:
Xercor Insurance Services LLC
8425 Woodfield Crossing Blvd, Ste 101E, Indianapolis, IN 46240
1-844-769-2904
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an enrollment form or in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Not applicable in AL, CO, DC, FL, KS, KY, LA, ME, MD, NJ, NM, NY, OH, OK, OR, PA, RI, TN, VA, WA, VT and WV.
Alabama-Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.
Colorado-It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company.Penalties may include imprisonment, fines, denial of insurance, and civil damages.Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
District of Columbia-WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
Florida-Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.
Kansas-Any person who knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.
Kentucky-Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
Louisiana-Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Maine, Tennessee, Virginia, and Washington-It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
Maryland-Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
New Jersey-Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
New Mexico-Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
New York-Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Ohio-Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Oklahoma-WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Oregon-Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law.
Pennsylvania-Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Rhode Island-Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Vermont-Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an enrollment form or in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.
West Virginia-Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
I hereby request to enroll in the Self Storage Tenant Insurance Program for the Amount of Insurance shown above. I have voluntarily elected to enroll in this Master Policy Insurance program, and I have read and completed this Enrollment form.
PRINTED NAME: _________________________________________
APPLICANT’S SIGNATURE: __________________________________ DATE SIGNED: _________________