Amity Insurance, an innovator in the insurance industry since 1978.

Insured Name*

Address

Suite

City

State*

Zip Code

Telephone*

Extension

Fax

Email Address*

Website

Location of Property (send schedule if necessary)

Number of Apartment Units

Number of Commercial Units

Building Construction
---FrameMasonryFire Resistive

Sprinkler System
 Yes No

Building Insurance Limit

Contents Limit

Annual Rents

Policy Expiration Date

Current Premium

Present Insurance Company