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Safe Stor Addendum Generic

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Mike Packer
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14 views

Safe Stor Addendum Generic

Uploaded by

Mike Packer
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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Facility Name:______________________________________

TENANT ACKNOWLEDGMENT
ADDENDUM

FIRE TORNADO WIND EARTHQUAKE HAIL BURGLARY VANDALISM VERMIN LIGHTNING SMOKE BUILDING EXPLOSION LEAKING FLOOD
COLLAPSE WATER

You are responsible to have coverage for your stored items


I understand that this storage facility does not insure my goods and is not responsible for damage or loss
to my stored property.
• I confirm that this facility has recommended that I provide proof of insurance coverage or immediately obtain coverage for my stored property.
• I confirm that Safestor Tenant Insurance has been offered.

❏ Yes, I want to cover my stored items with Safestor Tenant


Insurance with the coverage limit selected. Coverage Limits Monthly Rates
• I understand that coverage is effective immediately at time of payment. $1,000_____________ $8.95
• I understand that the monthly rate to cover my stored goods is being collected by the $5,000____________ $11.95
facility and forwarded to the insurer as a courtesy.
$10,000____________ $21.95
• I understand that the storage facility is not responsible for paying my monthly
premium if I fail to make payments. $20,000____________ $40.95
• I understand that the facility may retain a portion of the monthly tenant insurance
premium payment to cover the administration of the policy.

❏ No, I decline participation in Safestor Tenant Insurance.


• I understand that by declining coverage I am completely responsible for any loss or damage to my property including but not
limited to: mold, vermin, water damage, fire/smoke, tornado/wind, earthquake, lightning/hail, and burglary.
• I understand that the storage facility is not responsible for loss or damage to my stored goods and agree to hold this storage facility
harmless.

Insurance Company Name:_____________________________________________________________________________

Type: Homeowners Renters Business Owners Other________________________________________

Policy #: ___________________________________ Deductible: _____________________ This enrollment form contains only a general
description of coverage and does not
I acknowledge that I have read the above information and have selected the best option for me. constitute an insurance contract.
The facility will provide you a
Certificate of Insurance.
Customer Signature:__________________________________ Date:__________________________ Any person who knowingly or willfully
presents a false or fraudulent claim
for payment of a loss or benefit or who
Print Name: ________________________________________ Unit #:_________________________ knowingly or willfully presents false
information in an application for insurance is
guilty of a crime and may be subject to fines
Producer Signature:__________________________________ P. Blake Johnson, Producer and confinement in prison.

RWI-396(0) XXXXX-XXX(0) 09/23 ©2023 Ponderosa Insurance Agency WHITE - CUSTOMER CANARY - FACILITY

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