Home and Umbrella Insurance Application

HOME AND UMBRELLA INSURANCE APPLICATION

Applicant / Insured Information

Property to Be Insured

Coverage Requested

Dwelling Coverage Limit:   Other Structures Limit:

Personal Property Limit:   Loss of Use / Additional Living Expense Limit:

Liability Limit (per occurrence):   Medical Payments (per person):

Umbrella Liability Coverage

Optional / Additional Coverages

Select any additional coverages requested:

Prior Insurance and Loss History

Have you had any losses, claims, or incidents in the past five years? No Yes

Protective Devices and Risk Management

Named Additional Insureds / Beneficiaries

Add any additional persons or entities to be named on the policy, including mortgagees, loss payees, or additional insureds.

Exclusions and Important Policy Provisions

The policy applied for excludes coverage for loss or liability arising directly or indirectly from: war or hostile acts; nuclear hazard; intentional acts or criminal conduct of the insured; losses resulting from wear, gradual deterioration, latent defect, corrosion or mechanical breakdown; loss due to flood unless a separate flood endorsement or policy is obtained; and losses specifically excluded by endorsement. Additional limitations and exclusions may apply; coverage is subject to the terms, conditions, endorsements and exclusions of the actual policy issued.

Declarations, Authorization and Fraud Notice

I declare that the statements and answers contained in this application are true and complete to the best of my knowledge. I understand that material misrepresentation, omission, or concealment of fact may result in denial of coverage, rescission of the policy, or other remedies available to the insurer. I agree to notify the insurer promptly of any material change in risk prior to policy issuance or during the policy period.

I authorize the insurer and its representatives to obtain underwriting, claim and loss history information, including consumer reports, CLUE or other claim history databases, and to conduct inspections of the described property. I further authorize any prior insurer, employer, or claimant to release claim or loss information to the insurer for underwriting and claim handling purposes.

WARNING: Where applicable by statute, any person who knowingly presents a false or fraudulent claim for payment of a loss or who knowingly presents false information in an application for insurance may be guilty of insurance fraud and subject to penalties under the law.

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