Insurance Application for Property

Insurance Application for Property

Applicant / Insured Information

Applicant Name:

Date of Birth:    Social Security Number or Tax ID:

Property Details

Property Type: Single-family Multi-family Condominium Commercial Vacant land

Construction Type: Wood frame Brick Masonry Steel/Concrete

Year Built:    Square Footage:    Number of Units (if applicable):

Occupancy Status: Owner-occupied Tenant-occupied Vacant

Smoke detectors Burglar alarm Fire sprinklers Deadbolt locks

Policy Details

Policy Type: Basic Fire All Perils (Comprehensive) Named Perils Liability only Flood (separate endorsement) Earthquake (separate endorsement)

Deductible:    Annual Premium (estimated):

Policy Period: From to

Replacement cost endorsement Ordinance or law coverage Scheduled personal property Loss assessment coverage

Exclusions

The insurer will not provide coverage for loss or damage caused by, resulting from, or contributed to by: intentional acts by the insured, wear and tear, gradual deterioration, vermin, mold or fungi, pollution or contamination, war, nuclear hazard, or any peril specifically excluded by endorsement to the policy. This list is illustrative and not exhaustive; the policy and endorsements define the full scope of exclusions. Applicant acknowledges that certain perils such as flood and earthquake may require separate endorsements and premiums.

Prior Insurance and Loss History

Prior Policy Period: From to

Any claims or losses in the last 5 years? Yes No

Mortgagee / Loss Payee / Beneficiary

Relationship to Insured:    Percentage of Proceeds:

Declarations and Certification

By signing this application the Applicant certifies that all answers and statements contained herein are true and complete to the best of the Applicant's knowledge and belief. The Applicant understands that any material misrepresentation, omission or concealment of fact may render the policy voidable or may prejudice coverage. The Applicant authorizes the insurer to obtain claims, credit, and underwriting information pertaining to the Applicant and the property from third party sources, and to disclose application and claim information to reinsurers and agents as necessary for underwriting and loss adjustment.

Applicant acknowledges that coverage is subject to the terms, conditions, limitations and exclusions of the issued policy and that no coverage is effective until a policy or binder is issued and the required premium is received by the insurer or its authorized representative. The Applicant understands inspections may be required and that failure to permit inspection may affect acceptance of the risk.

Fraud Warning: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a criminal offense and subject to penalties under state law, including denial of benefits and cancellation of coverage.

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