Business/Rental Insurance Registration Form Last Revised July 6, 2023 Page 1
BUSINESS/RENTAL INSURANCE REGISTRATION FORM
Registration is valid until the end of the calendar year and must be renewed annually by January 15
th
.
Property Information
A separate form is required for each property.
Property Address:
Block:
Lot:
Check all that Apply:
Property Owner Business Owner Other: ___________________________
Property Owner Information
This section is to be completed by the property owner only.
Property Owner Name:
Mailing Address:
Telephone Number:
Email Address:
Business Owner Information
Business Name:
Business Owner Name:
Mailing Address:
Telephone Number:
Email Address:
Business/Rental Insurance Registration Form Last Revised July 6, 2023 Page 2
Insurance Requirements
The level of insurance coverage required by Chapter 173 Licenses and Permits of the Code of the Borough of
Rockaway is below (must choose one). A certificate of insurance must accompany this application.
The owner of a business located within Rockaway Borough shall maintain liability insurance for
negligent acts or omissions in an amount of no less than $500,000 for combined property damage and
bodily injury to or death of one or more persons in any one accident or occurrence.
The owner of a rental unit or units located within Rockaway Borough shall maintain liability
insurance for negligent acts or omissions in an amount of no less than $500,000 for combined
property damage and bodily injury to or death of one or more persons in any one accident or
occurrence.
The owner of a multi-family home of four or fewer units, one of which is owner occupied, located
within Rockaway Borough shall maintain liability insurance for negligent acts and omissions in an
amount of no less than $300,000 for combined property damage and bodily injury to or death of
one or more persons in any one accident or occurrence.
Fees
Choose one (please note, all 2023 registrations are initial registrations).
Initial Business/Rental Insurance Registration:
$125.00
Renewal Business/Rental Insurance Registration:
$50.00
Certification
I, the undersigned, hereby affirm that I am the owner or authorized agent designated to act on behalf of the owner
for the abovementioned business or rental property and that all information is true and correct to the best of my
knowledge and agree to comply with all provisions of Chapter 173 Licenses and Permits of the Code of the Borough
of Rockaway.
Applicant’s Name:
Applicant’s Signature:
Date:
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For Office Use Only
Amount Paid:
Check Number:
Date Received:
Certificate No.
Date Issued:
