Homeowners Insurance Form

HOMEOWNERS INSURANCE APPLICATION & AGREEMENT

Parties and Recitals

Applicant Name:   Insurer Name:

WHEREAS, Applicant seeks to obtain homeowners insurance for the property described below and agrees to be bound by the terms and conditions set forth in this Agreement; and

WHEREAS, Insurer is willing to provide such insurance coverage subject to underwriting, payment of premium, and the policy terms contained herein; and

WHEREAS, the parties desire to set forth their respective duties, payment obligations, term and termination provisions, and other material terms in a single integrated agreement.

Applicant & Property Information

Primary residence    Seasonal/Secondary residence    Rental/Investment property

Coverage Selections & Limits

Dwelling Coverage Limit: $   Personal Property Limit: $

Liability Limit: $   Medical Payments Limit: $

Flood endorsement    Earthquake endorsement    Scheduled personal property

Scope of Coverage

The Insurer shall provide insurance coverage for the risks, property, and perils as set forth in the coverage selections above, subject to exclusions, conditions, limits, and deductibles articulated in this Agreement and the attached policy schedule. Coverage shall include loss or damage to the insured dwelling, other structures, personal property, and personal liability as specifically listed. The Insurer's liability shall be limited to the coverages purchased and to the amounts actually paid for a covered loss under this Agreement.

Payment Terms

Premium Amount: $   Payment Frequency:

Late Payment Fee: If any premium installment is not received by Insurer within days after the due date, a late fee of will be charged. Nonpayment of premium may result in cancellation after notice in accordance with the Term and Termination provisions below.

Term and Termination

Policy Effective Date:    Policy Expiration Date:

This Agreement shall commence on the Policy Effective Date and continue until the Policy Expiration Date unless earlier terminated in accordance with this Agreement. Either party may terminate this Agreement prior to expiration upon written notice to the other party specifying the effective date of termination. For nonpayment of premium, Insurer may cancel after providing the notice period required by the terms herein and applicable law.

Notice Period for Cancellation: days (unless otherwise required by applicable law). Upon termination, Insurer shall return any unearned premium in accordance with the policy's pro rata or short-rate provisions as specified in the policy schedule.

Claims, Subrogation & Duties After Loss

Applicant must provide prompt written notice of any loss, protect the property from further damage, and cooperate with Insurer's investigation. Applicant authorizes Insurer to conduct reasonable inspections of the insured property. Insurer may pursue subrogation against responsible third parties to recover amounts paid under this Agreement; Applicant shall cooperate with such efforts.

Confidentiality and Privacy

All nonpublic personal information obtained by Insurer in connection with this Agreement is confidential and shall be used only for underwriting, policy administration, claims handling, and as required by law. Insurer may disclose such information to third parties where necessary to perform the services herein or as permitted by law. Insurer shall implement commercially reasonable safeguards to protect confidential information.

Representations, Warranties and Applicant Certification

Applicant represents and warrants that all information provided in this Application & Agreement is true, complete, and accurate to the best of Applicant's knowledge. Applicant certifies that no material facts have been omitted and that Applicant will promptly notify Insurer of any material change in the risk or property condition.

Yes    No

Governing Law; Entire Agreement

This Agreement shall be governed by and construed in accordance with the laws of the state of , without regard to choice-of-law principles. This Agreement, together with any policy schedule and endorsements attached or referenced, constitutes the entire agreement between the parties and supersedes all prior oral or written representations and agreements relating to the subject matter hereof. No amendment or waiver shall be effective unless in writing and signed by both parties.

Miscellaneous Provisions

Assignment: Applicant may not assign this Agreement or any rights hereunder without Insurer's prior written consent. Severability: If any provision of this Agreement is held invalid, the remainder shall remain in full force and effect. Notices shall be in writing and delivered to the addresses provided above unless changed in writing.

Acknowledgment and Signature

By signing below, Applicant acknowledges receipt of this Application & Agreement, certifies the truthfulness of the foregoing statements, authorizes Insurer to obtain loss history and other underwriting information, and agrees that coverage will be bound only upon acceptance by Insurer and receipt of required premium or deposit as set forth above.

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