Homeowners/Dwelling Application

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Homeowners/Dwelling Application

Homeowners/Dwelling Application

Applicant *

Occupation *

Date of Birth

Inspection Contact

Phone

Insured Email

Prior Career

Expiring Premium

Expiring Date

Requested Effective Date

Requested Expiration Date

Mailing Address

State

City

Zip

Applicant Questions

Any insurance declined, cancelled or non-renewed within 5 Years?

Yes

Has Applicant had any laps in coverage?

Yes

Has Anyone with financial interest in the property been convicted of aroson, fraud or other crime related to a loss on property?If yes, Please explain in remarks section.

Yes

Has the insured declared bankruptcy, foreclosure or repossession in the last 5 years?

Yes

Policy Form

Occupancy

Any losses, whether or not paid by insurance, during the last 5 years, at this or any location?

Yes

(If Yes, provide details below)

LOSS HISTORY

(prior 3 years)

Date

Type of Loss

Cause

Amount

Open/Closed

Preventative Measures

Consumer Notice of Insurance Scoring Acknowledgement

To offer an accurate quote in connection with this application for insurance, we may use a credit-based insurance score developed by a third party based on information contained in the owner’s credit report. Future reports may be used to update or renew insurance. By proceeding with the quote, I confirm compliance with disclosure requirements.

COVERAGES/LIMITS OF LIABILITY

Dwelling/(A&A–HO6)
Other Structures
Personal Property
Loss of Use
Loss Assessment
Personal Liability
Medical Payments

DEDUCTIBLE SECTION

AOP Deductible
Exclude Wind
Wind Deductible %
Named Storm Ded. Option
Hurricane Ded. Option
Theft Deductible
Water Deductible

Rating Information

Year Built

# Families

# Stories

Sq. Footage

Protection Class (9/10 requires supplemental app)

Distance to Fire Hydrant (Feet)

Distance to Fire Station (Miles)

If Rented - # of weeks per year?

If Vacant – length of prior vacancy?

If Rented Is this dwelling available for rent through any home sharing program or website?

*Update Information (required if year built is >35 years old)

REMARKS/Additional Information

Has flood insurance been purchased to the full value of the Dwelling indicated in the Coverages/Limits of Liability section?	Yes No
Is property situated on more than one acres? If yes, # of acres: Land used for:	Yes No
Is the dwelling bank owned or is there an adverse possession or cloud on the title?	Yes No
Does the dwelling include any live knob and tube wiring?	Yes No
Does the dwelling include any fuses?	Yes No
Does the dwelling include a circuit breaker with less than 100 amps?	Yes No
Does the dwelling include a Federal Pacific (FPE) Stab-Loc electric panel?	Yes No
Does the dwelling include any lead piping as part of the plumbing system?	Yes No
Does the dwelling include any galvanized iron piping or cast iron piping?	Yes No
Does the dwelling include any polybutylene piping?	Yes No
Does the dwelling include any lead paint?	Yes No
Does the dwelling have any asbestos exposure, external siding included?	Yes No
Any trampoline on premises? If yes, is there a net surrounding trampoline? Yes No If yes, is the trampoline in a fenced yard? Yes No	Yes No
Any swimming pool on premises? If yes, is pool fenced with locked gate? Yes No If yes, any slide or diving board? Yes No If yes, above ground in ground	Yes No
Any business on premises? If yes, explain in remarks section.	Yes No
Is there a daycare located on premises?	Yes No
Any animals on premises? If yes, please provide number of animals, type, breed and bite history in remarks section.	Yes No
Is the dwelling for sale?	Yes No
Is the unit rented to students?	Yes No
Is the dwelling undergoing any renovation or construction? If yes, requires supplemental application.	Yes No
Is there a woodstove on premises? If yes, requires supplemental application.	Yes No
Is there a fuel tank on premises? If yes, Underground Basement Above Ground	Yes No
Is the dwelling on the National Historic Registry? If yes, tours? Yes No	Yes No
If tenant occupied, is the current tenant(s) in the process of being evicted?	Yes No
Was the structure originally built for other than a private residence and then converted?	Yes No

OPTIONAL COVERAGES		LIMITS
Personal Property Replacement Cost	Yes No N/A
Extended Replacement Cost	Yes No N/A	25% 50%
Water Backup Deductable	Yes No N/A	$5K $10K $15K $25K
Mold – property limit	Yes No N/A	$5K $10K $15K $25K
Mold – liability limit	Yes No N/A	$5K $10K $15K $25K
All Risk Coverage C (HO-6 Only, incl. w/ HO-5)	Yes No N/A
Equipment Breakdown Deductable	Yes No N/A
Earthquake on A&C Deductable	Yes No N/A
Catastrophic Ground Cover Collapse (FL only)	Yes No N/A
Sinkhole (If yes, complete additional questions below)	Yes No N/A
Personal Injury (primary occupancy only)	Yes No N/A
Identity Fraud (primary occupancy only)	Yes No N/A
Ordinance or Law (10% automatically incl. for HO forms)	Yes No N/A	10% 15% 25%
All Risk Coverage A (HO-6 Only)	Yes No N/A
Extended Glass Breakage & Vandalism (not available on vacant risks)	Yes No N/A
Increased Special Limits – Coverage C	Yes No N/A
Increased Limits on Business Property	Yes No N/A
Golf Cart – Physical Damage CoverageIf yes, provide Year, Make, Model, Serial # & Value.	Yes No N/A
Vandalism & Malicious Mischief (DP-1 only)	Yes No N/A
Theft of Building Materials (COC/Renovations)	Yes No N/A
Soft Costs Extension (COC/Renovations)	Yes No N/A
Extend Liability to Additional Location	Yes No N/A
Mandatory Evacuation Coverage (SC only)	Yes No N/A
RCV and Certain Non-building Structures	Yes No N/A
Limited Flood Coverage (HO6 only) Deductable	Yes No N/A